Pathways of Care

This Pathway is to be used for children and young people (age 0-19 years) who fulfil the assessment criteria for children with exceptional healthcare needs (CEN). However, professionals may find that they wish to include the larger group of children with complex needs if the Pathway proves to be helpful and encourages better and timely access to service. The pathway should be used by all practitioners who work with children with exceptional healthcare needs and will be made available for families as a source of information.

Please click on the bullet point topics on the right for good practice documents, guidelines and useful links.

More information on the aims of the pathway can be found in Background, Acknowledgements and Palliative Care.

Outcome

All children with exceptional health care needs are fully and appropriately assessed using the Functional Assessment Tool (found within the Support Needs System) and early support provided.

Measure

All children with exceptional health care needs are recorded within the SNS system (or a local equivalent) within 4 weeks of identification.

Outcome

All children with exceptional health care needs have an individualised Child's Plan with actions, outcomes, timescales and responsibility recorded and an allocated Named Person and Lead Professional.

Measure

All children with exceptional health care needs have an individualised Child's Plan.

Outcome

All children with exceptional health care needs will have a multi-disciplinary/multi-agency discharge plan that compliments their existing Child Plan, which should include assessment of the ongoing heath and social care needs of the child and family to ensure the safety and continuity of care at discharge.

Measure

The discharge plan will reflect

  • Children & young people and their parents/carers are fully and actively involved in discharge assessment, planning and decision-making.
  • Discharge plan considers the whole child and not just their healthcare needs
  • Discharge planning is not a one off event.
  • Evidence of Child's Plan with actions, outcomes, timescales and responsibility, Named Person and Lead Professional.

Outcome

All children with exceptional health care needs have an individualised Child's Plan.

Measure

All children with exceptional health care needs have an individualised Child's Plan with actions, outcomes, timescales and responsibility recorded and an allocated Named Person and Lead Professional.

Outcome

All children with exceptional health care needs have an individualised Child's Plan that includes plans for transition to adult services.

Measure

All children with exceptional health care needs have an individualised Child's Plan with actions, outcomes, timescales and responsibility recorded and an allocated Named Person and Lead Professional.

Child's Plan includes Transition Planning from age 14 onwards.