Transitions to adult services

For many young people CYPMHS will be able to support them and they will be discharged when interventions are complete before they are 18, for some young people, further support may be needed into adulthood. Most services in CYPMHS see people up to 18 years old. The ADHD medication pathway in East Cheshire sees people up to 16 years old.  After these ages, if needed, you may be seen by adult services. This can be a worrying time for young people and their families. We have developed processes together with adult services to make this change as smooth as possible for you.

Transition is not simply a handover between services: it is about preparing young people for independence, supporting their aspirations, and promoting wellbeing in every aspect of life. Services promote person-centred planning, co-production, and multi-agency collaboration to ensure timely, effective, and inclusive transitions.

This page gives information on what will happen if you move to adult mental health services, based on the service you are referred to. Your worker will talk you through your personal plan too.

Process

We know that that transitioning between services can increase anxiety in young people. Sharing information about the process can help young people prepare for the change.

The transition process will be started early in a gradual way to minimise disruptions for the young person and to support long-term positive outcomes. Planning helps to prevent mental health conditions getting worse.

A CYPMHS 0-18 worker will work closely with the young person and their family with a person-centred approach.

  • Young people and their families will be informed about adult services and involved in decisions.
  • Discussions will start from age 17, or earlier if necessary, and refer to adult mental health services from age 17.5 years. 
  • The CYP worker will link in with a named adult mental health worker.
  • The CYP and adult mental health workers will work together on the transition process if appropriate following discussion and/or assessment. There will be a transition lead in each service to assist with transitions.
  • There will be joint working between services up to 18.5 years if appropriate.
  • A health passport will be created with the young person to support this process.
  • This allows young people to become familiar with the new service and new team looking after them.
Frequently Asked Questions (FAQs)

Who will be involved?

There will be a named worker from CYP and from adult services. Young people and their parent/carers will be involved in discussions from the beginning of the process.

How long does it take?

Discussions about transitions start at age 17 for most young people. The transition stage is between 17.5 years and 18.5 years.

Who can I contact for more information

Please speak to your CYP worker who will be able to answer any questions you have about the process.

Process

Turning 18 and moving to adults eating disorder (ED) services can be a worrying time for young people and their families/carers. The information below explains the process and should help young people prepare for the change. This process is for young people who are seen by community ED teams and young people who are seen by the outpatients and day service at Cheshire & Merseyside Adolescent Eating Disorder Service (CHEDS).

A policy is in place to ensure well-planned transitions for all young people from community eating disorder teams into adult eating disorder services. This helps with communication, joint working and proactive planning of transitions. A joint transition plan designed by the individual transitioning, their family/carers, CYPMH and adult services will be developed as a care plan.

  • A CYP worker will discuss adult services with the young person and their family from age 17.
  • Transition age starts at 17.5 years, or earlier if necessary, with joint working to 18.5 years when appropriate.
  • Young people will be provided with adult ED service information leaflets with information about adult services, how they work and how they are accessed.
  • There will be a named CYP and adult ED clinicians to support transition.
  • A joint transition session will be arranged for young people and their families. There will be opportunity for the young person to become familiar with the new service and new team looking after them.
  • A handover will take place which ensures that the new team have an up-to-date care plan and risk assessment.
  • The young person will be discharged from CYPMH as appropriate following completion of a post-transition meeting or an agreed period of joint working (where appropriate).
  • In some cases, if there is ongoing work, the CYP worker may work with the young adult alongside adult services up until age 18 years and 3 months.
Referral Criteria

If the transition referral does not meet criteria, CYP EDS will continue working with the young person in line with their goal-based care plan. 
CYPMH will review relapse prevention plan, review potential support services and discharge plan.
This may, in exceptional circumstances, involve continued input post 18 years for young people whose needs are viewed as more complex.

Frequently Asked Questions (FAQs)

Who will be involved?

There will be a named worker from CYP and from adult services. Young people and their parent/carers will be involved in discussions from the beginning of the process.

How long does it take?

Discussions about transitions start at age 17 for most young people. The transition stage is between 17.5 years and 18.5 years.

Who can I contact for more information

Please speak to your CYP worker who will be able to answer any questions you have about the process.

Process

For young people who have learning disabilities (LD), autism, mental health needs or a combination of these, the move from children’s to adult services can be a difficult time for them and their families and carers. By sharing information about the process we hope that everyone involved feels more prepared for the change.

A named CYP worker will participate in multi agency transition discussions where ongoing adult support is anticipated. Not all young people open to LD CAMHS will need a transition to adult LD services.

A five stage pathway has been developed for transitions:

  • Stage 1 - Early preparation
  • Stage 2 - Preparation for adulthood
  • Stage 3 - Pre-handover  
  • Stage 4 - Transfer to adult services
  • Stage 5 - Post-transition review

The process is person-centred and co-produced with the young person and their family/carers as equal partners. Families/carers are fully engaged and supported throughout.
The transition is developmentally appropriate, strengths-based, and focuses on aspirations and positive outcomes across education, employment, health, wellbeing, housing, and community inclusion.

  • Preparation starts from 17.5 years, or earlier if required. 
  • Plans are reviewed annually and updated as needs change.
  • Planning is based on anticipated needs and aspirations, not just current service use.
  • There will be a named worker responsible for coordinating the transition plan across agencies, ensuring clarity of roles and accountability.
  • The young person will be provided with clear, timely information to support handover, such as health summaries or health passports.
  • For young people with an Education Health Care Plan (EHCP), transition is reflected within EHCP reviews.
  • Young people meet adult service practitioners before transfer and are supported to build confidence and decision-making skills for independence.
  • Formal handover of responsibility to adult health and/or social care services, where eligible, takes place at age 18.
  • Systems are in place for emotional and practical support after transition. This can be support to follow up missed appointments, ensuring reasonable adjustments are in place and acted upon.
  • Transition progress is monitored at key milestones, with post-transition reviews to inform future practice.

  • Post-transition review will take place within 6 months of transfer to adult services.

GPs and Primary Care

To ensure a smooth transition, continuity of care will be maintained before, during, and after transition. This includes shared care agreements for prescribing medication.

Frequently Asked Questions (FAQs)

Who will be involved?

There will be a named worker from CYP and from adult services. Young people and their parent/carers will be involved in discussions from the beginning of the process.

How long does it take?

Discussions about transitions start at age 17 for most young people. The transition stage is between 17.5 years and 18.5 years.

Who can I contact for more information

Please speak to your CYP worker who will be able to answer any questions you have about the process.

If you are being seen by the ADHD medication team you will be seen up to 16 years old. 

Find out more about the adult ADHD pathway for ages 16+ here.

Process

We know that that transitioning from Ancora House child inpatient to adult inpatient services can be a worrying time for young people. Sharing information about the process can help young people prepare for the change. This process is for young people referred to Ancora House for general mental health difficulties or to Cheshire & Merseyside Adolescent Eating Disorder Service (CHEDS) for treatment of complex Eating Disorders (both outpatient and inpatient).

We have developed 7 transition principles for high quality transition experiences for the young people using our services.

The 7 principles: 
1.    Service users experience person-centred, needs-led care.
2.    Services follow best practice and clinical standards.
3.    Services, partners and the community have a shared responsibility and vision.
4.    Early identification and meeting of needs.
5.    Improving health equity and reducing inequalities for service users.
6.    Staff have appropriate values, skills and knowledge.
7.    Services are developed and continually improved through coproduction.

Child to adult inpatient transitions will be well planned and coordinated. They will be person-centred, meaning the young person is central to decisions. The process ensures that the transition will be a seamless and optimal experience for the young person at this difficult and challenging time of their lives.

Not all young people need to transition as an inpatient from Ancora House to an CWP adult inpatient services​​ at age 18.

  • From age 17 Ancora House will refer to adult mental health inpatient services.
  • At age 17.5 years a meeting will be held between child and adult inpatient services.
  • The adult team will attend transition planning meetings with children's services until the transition happens at age 18.

When the need for child to adult inpatient transition is confirmed:

  • An adult ward will be allocated.
  • 7 to 14 days before the transition date, orientation visits will be arranged to the adult ward. This allows young people to become familiar with the new service and new team looking after them
  • Reasonable adjustments such as visual guides may be used to help prepare for the change.
  • A clear plan will be agreed between the child and adult ward about how and when the transition will take place.
  • After the transition has taken place and the young person is settled, they will be asked for feedback.

Should a young person require on-going admission beyond their 18th birthday, but an adult bed has not yet been identified, arrangements would be made for the young person to be supported by a member of staff at all times due to the fact they will be deemed an adult nursed on a young person’s ward.

Frequently Asked Questions (FAQs)

Who will be involved?

There will be a named worker from CYP and from adult services. Young people and their parent/carers will be involved in discussions from the beginning of the process.

How long does it take?

Discussions about transitions start at age 17 for most young people. The transition stage is between 17.5 years and 18.5 years.

Who can I contact for more information

Please speak to your CYP worker who will be able to answer any questions you have about the process.