Continuing Care is directed by the Welsh Government’s Children and Young People's Continuing Care Guidance (January 2020).

A continuing care package may be required when a child or a young person has long-term health needs arising from e.g. physical and learning disabilities, mental health needs, neurodevelopmental disorder and behaviours which may be considered challenging and cannot be met by existing universal or specialist services alone. (See documents in resources below for examples of these services).

Diagnosis of a particular disease or condition is not in itself a determinant of a need for continuing care.

The guidance covers young people up to their 18th birthday. Thereafter, the Continuing NHS Healthcare for Adults in Wales Framework for NHS Continuing Healthcare and NHS-funded Nursing Care and the supporting guidance and tools should be used.

There are significant differences between children and young people’s continuing care and NHS Continuing Healthcare for Adults. Although a child or young person may be in receipt of a package of Continuing Care, they may not be eligible for Continuing NHS Healthcare for Adults or NHS Funded Nursing Care once they turn 18.

How to access

If you think your child may be eligible for Children and Young People's Continuing Care support, please contact your social worker or any other health or social care professional involved in your child’s care for advice. If appropriate, they will make a referral to Cardiff and Vale University Health Board's Children and Young People’s Continuing Care Service.

Process to Assess Eligibility for Children and Young People's Continuing Care

• We require parental consent to enable us to gather relevant information from professionals involved in your child's care.
• Following consent being given, the referring health or social care professional will complete a referral form which needs to be sent to the Children’s Continuing Care Manager who, along with multi-agency colleagues, will determine whether or not a full assessment is necessary.
• If a full multi-agency assessment is indicated, the Continuing Care Manager and an allocated nurse assessor will arrange for multi-agency assessments, reports and information to be sought from the child or young person’s multidisciplinary team (MDT) and a Continuing Care Decision Support Tool (DST) will be completed. The child/young person, their Parents and/or their representative will be invited to contribute to the assessment and give their views.
• Following the completion of the decision support tool, the MDT will make a recommendation regarding eligibility and a proposed care package.
• The recommendation will be presented to the Multi Agency Continuing Care forum who will support or seek further information, based on all the supporting evidence and information received from parents, carers and the professionals involved in the child's care.
• Everyone involved will be informed in writing of the decision along with a full reason for the decision.

The University Health Board (UHB) will aim to ensure that the whole process from referral to decision should not take longer than six weeks (as per Welsh Government Guidance); however, given the complexity and variety of needs which the UHB may be assessing, there is scope for flexibility.

Reviews of decisions made by Continuing Care 

Parents/carers are encouraged to contact the Continuing Care manager as soon as possible if they are unhappy with any part of the Continuing Care process.

Whilst engagement and transparency is aimed to reduce the likelihood of complaints, disputes or appeals, there may be times when this occurs.

The University Health Board would like to make sure that you find it as easy as possible to request a review of a continuing care support eligibility decision. We will ensure that reviews are acted on fairly and resolved quickly.

Resources

• Welsh Government Children and Young People's Continuing Care Guidance 2020
• Guidance Annexes

Universal Services                                          

Universal Services are services which are available to all children and young people no matter what their circumstances and include provision by health, education and voluntary services. Examples include:

• GP services
• Health visiting
• Nursery
• Primary and Secondary School

Specialist Services

Specialist services are specific services which generally have referral criteria and require both referral and regular review. Children and young people may move in and out of these services depending on need. Examples include:

• Community Paediatrician
• Occupational Therapy, Speech and Language Therapy, Physiotherapy
• Community Children’s Nursing
• Learning Disability Nurse
• Children and Adolescent Mental Health Services (CAMHS)
• Children’s Intensive Therapy Team (CITT)
• Psychology Services
• Children’s Intensive Support Services (CISS)
• Individual Development Plan
• Team around the Family (TAF)
• Integrated Disability Team
• Children with Disability team

Useful Links

• Noah's Ark Children's Hospital for Wales                         
• Children's Services, Cardiff Council   
• Children's Services, Vale of Glamorgan

Contact

Contact number: 02921 836544
Email: Cav.Continuingcare_child@wales.nhs.uk

The Team is based at:

Woodland House
Maes y Coed Road
Cardiff
CF144HH