Shared Decision Making in Transition Feedback from Aqua project – October February 2015

Case Study Elle Currently attending Special Educational College setting – leaving June 2015 Under care of Endocrinology Consultant Diagnosis of Severe Learning Disability/ physical disability Loves socialising; meeting friends; family; boyfriend – shopping / eating out/ Duke of Ed Elle would like to increase independence – both in and outside the home Diagnosis affects mobility – Physio in past/ risk of falls O/T Elle/ parents would like to increase mobility/ worried about falls Ready Tool’s completed with Elle and mum as part of Transition Assessment EHC Process/ Social Service assessment Primary Care to take lead role in health support 19 years old

Successes in 2014 Shared Decision Making/ Person-Centred Planning – we do that anyway but… Aqua Project has highlighted tools and the wider issues: Motivational Interviewing Ready Steady Go questionnaires Parent Involvement Strengthening links between Paediatrics/ Adult Therapists Introducing measurement for Shared Decision Making to provide evidence Aqua team learning/ problem solving together

Challenges to date: System Issues EHC process Individual Health Budgets Clarity of Local Offer Referral Criteria’s/ process affecting choice (including partner services) Transition/ Discharge on to Primary Care –how to influence SDM in Primary Care Operational Issues Time to meet with/ joint work within the Team affects momentum Small cohort – data collection is minimal/ questions not good fit for our cohort Geographically dispersed/ diverse leadership arrangements

Addressing Challenges System Issues Difficult to address wider issues but: Reviewing pathways between Paediatric/ Adult Therapy Services Utilise Primary Care Access Team to introduce RSG Tools to Primary Care colleagues Operational Issues Starting to embed Tools into the transition pathway (HEF and RSG) Devising Case Study due to small cohort – highlights complexity of transition for young people with Learning Disability across health and social care

Data collection:

Our Stakeholders Adult therapy teams Adult Service Providers NHS Continuing Care Team CiCs Day services (LA Funded) Bridgewater Adult Learning Disability service Adult Bridgewater Services Bridgewater Paediatric Services ALD Transition social work Children’s Social Work Team WWL Medical Staff SEND Team – Special Education Needs Team Community Paediatricians AQUA Shared Decision Making Team How do we communicate about the project with other key teams? Where recipients of healthcare and their families are more informed and involved in decisions, care is safer and more effective. Our Shared Decision Making Project, in partnership with AQuA aims to improve the way our clinicians engage, involve and interact with young people and their carers during the process of transition to ensure they are ready and well equipped, to make decisions about and access healthcare; supporting them with asking the right questions.