The Children’s Continuing Care team is a nurse-led service. All assessments are carried out by nurses. Within the team there is a mix of paediatric and learning disability nurses, supported by administration staff.

Where eligible, NHS North Yorkshire CCG (NHS Humber and North Yorkshire ICB from July 2022) provides a package of care to a child or young person with complex health care needs. This can be within the family home, respite outside of the family home or to support access to community activities.

Referrals can be made by any professional working with a child or young person and their family, eg. social worker, community nurse, GP, hospital discharge planning nurse.

Consent for Children’s Continuing Care is obtained by the referrer when discussing the referral with the child or young person (if appropriate) and their family.

The referrer needs to submit:

• A completed application form
• A completed checklist
• Consent form
• Education, Health and Care Plan, if the child or young person has one
• Any supporting clinical information

The Children’s Continuing Care nurse will make a decision based on all the information provided by the referrer to determine if an initial assessment should be undertaken to begin the process of assessing eligibility for continuing care.

The initial assessment will be coordinated by a nurse from the Children’s Continuing Care Team who will initially obtain reports and recent clinical information from the multi-disciplinary team who are involved in the child or young person’s care.

The nurse will complete the initial assessment with input from the child or young person (if appropriate), their family and any health professionals who work with the child or young person as well as from education and social care professionals, to determine whether or not a full assessment is necessary.

Where a full assessment in required the nurse will complete a Decision Support Tool in line with the National Framework for Children and Young Peoples Continuing Care to determine eligibility.

If a child is eligible a package of care is discussed with the child or young person (where appropriate) and their family and the best way of managing it is discussed with the family eg. Personal Health Budget, provided by a care agency.

If a child or young person needs an urgent package of care because of a rapidly deteriorating condition, which may be entering a terminal phase, we will use the Fast Track Tool.

An appropriate clinician will complete the assessment to determine eligibility for NHS Continuing Care and arrangements will be made to provide care as quickly as possible.

If a professional working with a family is considering making a referral they are encouraged to call or email the team to discuss (0300 303 8674 or email nyccg.childrenscontinuingcare@nhs.net). The team is part of the multidisciplinary integrated team supporting children, young people and their families.