Why do we provide transition services? Because we recognise that change and transitions can be daunting for some individuals. This plan is designed to support our customer’s move from childhood, where parents make decisions on their behalf, to adulthood where they make their own decisions – as they learn to direct and control their own lives.

Throughout the transition planning our Case Leaders focus on positives and what is possible for the individual to achieve rather than a pre-determined set of criteria, taking into consideration the individual’s capabilities, condition and future aspirations. We feel our strength-based approach is essential to capture what our customers can and will do within their plan.

We ensure the young person is listened to throughout the process. By co-producing the plan with the individual, we are able to identify our customer’s goals and outcomes that they wish to achieve together with the review and monitoring of the support.

Support staff are permanently allocated to our customers in order that they can truly understand the customer’s needs and levels of support.
Our Case Leaders are the link between our service and customer and work closely with practitioners including:

  • GP’s
  • Case Managers
    Occupational Therapists
  • Physio Therapist,
  • Dietitians
  • Social Services- Key Workers

As confidence grows, our Case Leaders will maintain their involvement to monitor and review the transition, providing reassurance where necessary and assisting our customer to become familiar with the adult services and personnel involved. We ensure opportunity is given to our customers to test different ways of managing their care in order that their confidence continues to build and that over time they can take ownership.

Transition Services: Paul’s Story

Paul lived in his family home with his mother who was separated from his birth father. Paul has Cerebral Palsy which physically impacted on his posture and mobility. He aspired to lead an ordinary life and live independently in adulthood in his own house, managing his daily living tasks with support.

Having commenced supporting Paul whilst he still lived at his family home, Caremark introduced a Key-Worker (Caremark’s Case Leader) who developed a relationship with Paul that enabled everyone to understand, recognise and establish his long-term goals and aspirations. This enabled Paul to be at the centre of his long-term planning, establishing what was important to him as he transitioned into adulthood. Caremark involved Paul’s circles of support, family, friends, health professionals, housing associations and adult services to ensure Pauls aspirations were heard. Through this collaborative planning, Paul was able to develop a transitions plan with Caremark that encompassed his short and long-term goals with clear time frames establishing ‘what’ when’ ‘who’.

Caremark met regularly with family and professionals to ensure the transition to adult services met all his needs and his property, education and care package was appropriate to his needs. Paul’s Key-Worker (Caremark’s Case Leader) together with his support team provided reassurance, and consistency and over time he gained confidence which enabled him to enjoy an independent life and achieve his goals.

The Plan

  • The plan captured and incorporated Paul’s choices outlining a pathway that encompassed:
  • Housing-related support: new property, layout adaptations, budgets & home finances.
  • Support with life skills: meal planning, cooking and daily living & household tasks.
  • Education: support to attend college consistently maintaining his right to education.
  • Pathway to employment through Greenworks.
  • Social engagement: Planning holidays, travel, attending evening classes (Karate).
  • Goal setting: plans to attend activities of interest such as football, karate, cinema, competitions & motor racing.
  • Ongoing consistent support in his own home and community from Caremark.

Transition Services: Sarah’s Story

Sarah has Cerebral Palsy and was finding life difficult living in her family home living with her parents. The environment did not lend itself to meeting her aspirations to live independently as she transitioned into adulthood. She wished to make her own choices whilst being supported with her health needs.

Sarah moved into a rehabilitation centre as a stepping-stone to living in her own house independently. Caremark commenced working with Sarah in the rehabilitation centre providing personal care support whilst establishing her aspirations, focussing on what she could do and achieve. We developed a plan in collaboration with her rehabilitation programme designed to support her future independent living goals.

Sarah’s Key-Worker (Caremark Case Leader) worked with Sarah and her circles of support to ensure key people that were important to her and key professionals were involved in supporting Sarah to make choices about her Independent living. Working closely with Sarah and her independent Case Manager, we developed a shared vision and plan that ensured a seamless transition relocating from a rehabilitation establishment, enabling Sarah to live independently, safely supported in her own home with a consistent support team from Caremark. Sarah is supported to make her own decisions with regards to her everyday living. She participates in social evenings with friends and enjoys relationships with family that may not have been possible if she did not have her own space.

The Plan

Caremark’s team worked with Sarah’s Case Manager and financial advocate to establish a seamless pathway into her
own home. This encompassed:

  • Supported visits to view potential properties.
  • Home adaptions and aids.
  • Providing information for Sarah to choose furnishings.
  • Staged visits to her new home.
  • Staged stay overs in her new home, extending the duration each week.
  • Comprehensive Care Plan – Personalised care and daily living support needs.
  • Short & Long Term risk accessing.
  • Established protocols respecting Sarah’s wishes relating to visitors.
  • Health plans: Specific nursing needs and support to health appointments.
  • Developing daily living skills and household
  • maintenance programmes.
  • Future goals: Social Activities/ Interests -Hydrotherapy Pool.

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