INTEGRATED ANTENATAL TRANSITION OF CARE PATHWAY … years/eyc key messages/April...appropriate care...
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In consultation with COMMUNITY Members of the Midwifery Children's Centre and Health Visiting team will work in partnership through transition of care from the antenatal to the postnatal period. These early years professionals will: • Promote effective communication between the Midwife, Children's Centre and Health Visitor to promote early intervention where a needs are identified at any point in pregnancy from booking onwards. • Build links with voluntary services. • Follow standard operating procedures to ensure all involved professionals are alerted to failed pregnancies. UNIVERSAL/STANDARD • Antenatal notification will be provided by the Midwife at 28 weeks of pregnancy to the Children's Centre and Health visiting Team using copy of booking form showing consent to share with Children's Centre. • Midwifery care to continue as planned. • Health Visiting Admin team will register mother on SystmOne. • The Health Visitor will review each expectant mother’s health record if available prior to making first contact. • All mothers will be offered a face-to-face Health Visitor ante-natal contact from week 28 of pregnancy, as per core offer . If visit is declined or no contact is made details of HV service and Children's Centres sent by letter and recorded on SystmOne. UNIVERSAL PLUS/INTERMEDIATE Additional services that the family may require if a need for extra support is identified at any point in pregnancy . UNIVERSAL PARTNERSHIP PLUS/INTENSIVE Families identified as needing additional targeted support for issues such as safeguarding, domestic abuse, mental health, poor physical health at any point in pregnancy . INTEGRATED ANTENATAL TRANSITION OF CARE PATHWAY Telephone or face-to-face handover between Midwife and Health Visitor to be carried out. Appropriate professional may make a referral to Social Care. Review Family’s goals achieved? Signpost family to Community. Family’s goals NOT achieved? Consider options for further support / refer to Universal Partnership Plus. Antenatal contact by Health Visitor to take place from 28 th week of pregnancy. Family’s goals NOT achieved? Professional review of family / see supervision. Family’s goals achieved? Continue support through Universal Plus service / Universal settings. Liaison between Health Visitor and Midwife to continue until discharge. Health Visitor / Midwife to attend relevant meetings. Health Visitor will receive a discharge notification from Midwifery services. Professionals to identify what support services are already in place for the mother and family and signpost to further channels of support if required (e.g. early intervention Team/ CAF ). Offer support to mother and family as required. Review as per individual care plan. 1 Jane Webster - Clinical Lead Health Visiting August 2015
Transcript of INTEGRATED ANTENATAL TRANSITION OF CARE PATHWAY … years/eyc key messages/April...appropriate care...
In consultation with
COMMUNITYMembers of the Midwifery Children's Centre and Health Visiting team will work in partnership through transition of care from the antenatal to the postnatalperiod. These early years professionals will:• Promote effective communication between the Midwife, Children's Centre and Health Visitor to promote early intervention where a needs are identified at
any point in pregnancy from booking onwards.• Build links with voluntary services.• Follow standard operating procedures to ensure all involved professionals are alerted to failed pregnancies.
UNIVERSAL/STANDARD• Antenatal notification will be provided by the Midwife at 28 weeks of pregnancy to the Children's Centre and Health visiting Team using copy of booking
form showing consent to share with Children's Centre.• Midwifery care to continue as planned.• Health Visiting Admin team will register mother on SystmOne.• The Health Visitor will review each expectant mother’s health record if available prior to making first contact.• All mothers will be offered a face-to-face Health Visitor ante-natal contact from week 28 of pregnancy, as per core offer . If visit is declined or no contact is
made details of HV service and Children's Centres sent by letter and recorded on SystmOne.
UNIVERSAL PLUS/INTERMEDIATEAdditional services that the family may require if a need for extrasupport is identified at any point in pregnancy .
UNIVERSAL PARTNERSHIP PLUS/INTENSIVEFamilies identified as needing additional targeted support for issues suchas safeguarding, domestic abuse, mental health, poor physical health atany point in pregnancy .
INTEGRATED ANTENATAL TRANSITION OF CARE PATHWAY
Telephone or face-to-face handover between Midwifeand Health Visitor to be carried out. Appropriate professional may make a referral to Social Care.
Review
Family’s goals achieved?Signpost family toCommunity.
Family’s goals NOT achieved?Consider options for furthersupport / refer to UniversalPartnership Plus.
Antenatal contact byHealth Visitor to takeplace from 28 th week ofpregnancy.
Family’s goals NOTachieved?Professional review offamily / see supervision.
Family’s goals achieved?Continue support throughUniversal Plus service /Universal settings.
Liaison between HealthVisitor and Midwife tocontinue until discharge.
Health Visitor / Midwife to attend relevant meetings.
Health Visitor willreceive a dischargenotification fromMidwifery services.
Professionals to identify what support services are alreadyin place for the mother and family and signpost to furtherchannels of support if required (e.g. early interventionTeam/ CAF ).
Offer support to mother and family as required.
Review as per individual care plan.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYMembers of the Health Visiting team will work towards supporting the transition to parenthood and helping parents make informed decisions that enhanceoutcomes for children and families by:* Building links with local services, including Children’s Centres, to improve access to provision within the community.* Ensuring families know how to access the Health Visiting service for further help and support.* Promoting and working to the Baby Friendly Initiative Standards.
UNIVERSALOn receiving notification of pregnancy from Midwifery provider it is mandatory to carry out a face to face contact after 28 weeks gestation. As part of thiscontact an initial holistic assessment of need will be completed incorporating the Solihull Approach and Motivational Interviewing Techniques. There will be afocus on emotional preparation for birth, the carer-infant relationship, care of the baby, parenting and attachment and infant development. Information willalso be provided on the Healthy Child Programme, the Healthy Start Scheme and the Personal Child Health Record. Reducing the risk of SIDS will be discussedin line with current Department of Health Guidelines. Ensure the named Health Visitor (HV) is added to Groups & Relationships on SystmOne and mum isnotified of named HV. There must be 2 attempts of contact either by letter or phone, if unsuccessful HV will review the record and act accordingly.
UNIVERSAL PLUSAdditional services that the family may require if a need for extrasupport is identified.
UNIVERSAL PARTNERSHIP PLUSFamilies identified as needing additional targeted support for issues such assafeguarding, domestic abuse, LAC, mental health, poor physical health. Seekappropriate care pathway for specific guidance and refer to specialist services asappropriate, maintaining service delivery.
HEALTH VISITING SERVICE - INTEGRATED ANTENATAL PATHWAY
Family signposted to other services.Examples could include:• Smoking cessation.• Housing.• GP / Midwife.• Early Intervention Team/children’scentres.• Community Mental Health Service.• Breastfeeding Support.
HV to develop a care plan & deliver evidence basedinterventions in line with agreed partnershippathways.
Review within 6 weeks
Family’s goals achieved:Ensure family know how to accessthe Health Visiting Service.
Family’s goals not achieved:- Review action plan .- Seek supervision to plan next steps .- Consider referral to Children’s Social Care.
On going support from theHealth Visiting Service.
Family’s goals notachieved� Review action planand goals with thefamily.� Request multi-agency review.� Seek supervision.� Plan next steps.
Family’s goals achieved� Ensure family knowhow to access theHealth Visiting Service.� Plan next steps withfamily or other servicesas appropriate.
Ensure appropriate safeguardinginterventions are in place to reduce risks& improve health & wellbeing of childrenfor whom there are safeguarding & childprotection concerns.
Review
HDFT SafeguardingChildren’s Policy.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYMembers of the Health Visiting team will work towards improving the transition to parenthood and helping parents make informed decisions that enhanceoutcomes for children and families by:• Building links with local services to improve access to provision within the community.• Ensuring families know how to access the Health Visiting service and further help and support.• Promoting and working to the Baby Friendly Initiative Standards.
UNIVERSALIt is mandatory to carry out a home visit within 14 days of delivery. The holistic assessment will continue on from the Antenatal contact and will incorporate theSolihull Approach and Motivational Interviewing Techniques. At this contact the Health Visitor will use professional judgement when carrying out a growthassessment, contact details of the Health Visiting service will be given to the family, also included is Infant feeding, promoting sensitive parenting, promotingdevelopment, assessment of perinatal mental health, promotion of safe sleep and SIDS reduction, keeping safe, promotion of immunisations, check status ofscreening results – hearing, blood spot and NIPE, provide information on local children’s centres and complete notification for family registration and forwardto children centre. Ensure the named HV is added to Groups & Relationship on SystmOne and Mum is notified of named HV.
UNIVERSAL PLUSAdditional services that the family may require if a need for extra support is identified.
UNIVERSAL PARTNERSHIP PLUSFamilies identified as needing additional targetedsupport for issues such as safeguarding, domestic abuse,LAC, mental health, poor physical health. Seekappropriate care pathway for specific guidance and referto specialist services as appropriate, whilst continuing toprovide the Universal and Universal Plus offer.
Health Visiting Service – New Birth Visit
Family signposted toother services. Examplescould include:• Smoking cessation.• Housing.• GP / Midwife.• Early InterventionTeam / children centres.• Community MentalHealth Service.• Breastfeeding Support.
Review
Review within 6 weeks
Family’s goals achieved:Ensure family know howto access the HealthVisiting Service.
Family’s goals not achieved:• Review action plan.• Seek supervision to plan next steps.• Consider referral to Children’s Social Care.
Ensure appropriatesafeguardinginterventions are inplace to reduce risks& improve health &wellbeing of childrenfor whom there aresafeguarding & childprotection concerns.
Family goals notachieved:� Review action planwith family.� Seek Supervision.
Family’s goals achieved:� Ensure family knowhow to access theHealth Visiting Service.� Plan next steps withfamily or other servicesas appropriate.
HDFTSafeguardingChildren’sPolicy.
Ongoing support fromthe Health VisitingService e.g. childrenwith disabilities,promotion ofimmunisation towomen who are HepB+ve and ascertainmaternal rubella statusand follow upvaccination if required.
HV to develop a care plan and deliver evidence basedinterventions in line with agreed partnership pathways.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYMembers of the Health Visiting team will work towards improving the transition to parenthood and helping parents make informed decisions that enhanceoutcomes for children and families by:* Building links with local services to improve access to provision within the community.* Ensuring families know how to access the Health Visiting service and further help and support.
UNIVERSALIt is mandatory to carry out a face to face contact with all families with a baby of between 6 weeks (exactly) and 7 weeks 6 days of age, this must also berecorded on SystmOne within this time frame, this contact should take place at home or in a venue suitable to a one to one situation when privacy and dignitycan be assured. The Solihull Approach and Motivational Interviewing Techniques will continue to be used. There will be a focus on the assessment of perinatalmental health (PMH), growth measurements – weight, length and head circumference to be recorded, infant feeding status to be ascertained, relevant healthpromotion advice, bookstart packs to be given to all families with an explanation of its purpose role of baby brain development, explore with parents widerfamily support, relationships within the family, family health needs and isolation. Assess the impact of the birth on the family.
UNIVERSAL PLUSAdditional services that the family may require if a need for extrasupport is identified. For mothers with an identified PMH mild tomoderate refer to pathway.
UNIVERSAL PARTNERSHIP PLUSFor mothers with identified with a severe PMH, please refer to the PMHpathway.Families identified as needing additional targeted support for issues such assafeguarding, domestic abuse, LAC, poor physical health. Seek appropriate carepathway for specific guidance and refer to specialist services as appropriate,whilst continuing to provide the Universal and Universal Plus offer.
Health Visiting Service – 6-8 week contact
Family signposted to other services.Examples could include:• Early Intervention Team /children’s centres.• Smoking cessation.• Housing.• GP• Community Mental Health Service.• Breastfeeding Support.
HV to develop a care plan & deliver evidence basedintervention in line with agreed partnershippathways.
Review within 6 weeks
Family’s goals achieved:Ensure family know how to accessthe Health Visiting Service.
Family’s goals not achieved:- Review action plan.- Seek supervision to plan next steps.- Consider referral to Children’s Social Care.
On going support from theHealth Visiting Service.
Family’s goals notachieved:� Review actionplan and goals withthe family.� Seek supervision.
Family’s goals achieved:� Ensure family knowhow to access theHealth Visiting Service.� Plan next steps withfamily or other servicesas appropriate.
Ensure appropriate safeguardinginterventions are in place to reduce risks& improve health & wellbeing of childrenfor whom there are safeguarding & childprotection concerns.
Review
HDFT SafeguardingChildren’s Policy.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYMembers of the Health Visiting service will work towards improving the transition to parenthood and helping parents make informed decisions that enhanceoutcomes for children and families by:* Building links with local services to improve access to provision within the community.* Ensuring families know how to access the Health Visiting service and further help and support.
UNIVERSALIt is mandatory for all children to be offered a face to face contact to be completed and recorded on SystmOne by the time the child is 12 months old.Incorporated within this will be the Solihull Approach and Motivational Interviewing Techniques. There will be a focus on the assessment of the baby’s growth,physical, emotional and social development and needs in the context of their family using evidence based tools, for example the Ages & Stages questionnaires .Supporting parenting, provide parents with information about attachment, development and parenting issues. Health promotion, raise awareness of dentalhealth and prevention, encouraging families to access primary dental care services for routine preventive care and advice, discuss healthy eating, injury andaccident prevention relating to mobility, safety in cars and skin cancer prevention. There must be 2 attempts of contact either by letter or phone, ifunsuccessful HV will review the record and act accordingly. This review may be carried out by an assistant practitioner.
UNIVERSAL PLUSAdditional services that the family may require if a need for extrasupport is identified.
UNIVERSAL PARTNERSHIP PLUSFamilies identified as needing additional targeted support for issues such assafeguarding, domestic abuse, LAC, mental health, poor physical health. Seekappropriate care pathway for specific guidance and refer to specialist services asappropriate, whilst continuing to provide the Universal and Universal Plus offer.
Health Visiting Service – 9-12 month Review
Family signposted to other services.Examples could include:• Smoking cessation.• Housing.• GP.• Early Intervention Team/ children’s
centres.• Community Mental Health Service.• Breastfeeding Support, Library’s.
HV to develop a care plan and deliver evidence basedintervention in line with agreed partnershippathways.
Review within 6 weeks
Family’s goals achieved:Ensure family know how to accessthe Health Visiting Service.
Family’s goals not achieved:- Review action plan .- Seek supervision to plan next steps.- Consider referral to Children’s Social Care.
On going support from theHealth Visiting Service.
Family’s goals notachieved:� Review actionplan and goalswith the family.� Seeksupervision.
Family’s goals achieved:� Ensure family knowhow to access theHealth Visiting Service.� Plan next steps withfamily or other servicesas appropriate.
Ensure appropriate safeguardinginterventions are in place to reduce risks& improve health & wellbeing of childrenfor whom there are safeguarding & childprotection concerns.
Review
HDFT SafeguardingChildren’s Policy.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYMembers of the Health Visiting service will work in partnership with their Early Years colleagues towards improving the transition to parenthood and helpingparents make informed decisions that enhance outcomes for children and families by:* Building links with local services to improve access to provision within the community.* Ensuring families know how to access the Health Visiting service and further help and support.
UNIVERSALIt is mandatory that all children will be offered a face to face contact to be completed and recorded on SystmOne between the ages of 2 – 2 ½ years of age.Incorporated within this will be the Solihull Approach and Motivational Interviewing Techniques. There will be a focus on the assessment of the child’s growth,physical, emotional and social development and needs in the context of their family using evidence based tools, for example the Ages & Stages questionnaires.Supporting parenting, provide parents with information about attachment, development and parenting issues. Health promotion, raise awareness of dentalhealth and prevention, encouraging families to access primary dental care services for routine preventive care and advice, discuss healthy eating, injury andaccident prevention relating to mobility, safety in cars and skin cancer prevention. There must be 2 attempts of contact either by letter or phone, ifunsuccessful HV will review the record and act accordingly. This review may be carried out by an Assistant Practitioner.
UNIVERSAL PLUSAdditional services that the family may require if a need for extrasupport is identified.
UNIVERSAL PARTNERSHIP PLUSFamilies identified as needing additional targeted support for issues such assafeguarding, domestic abuse, LAC, mental health, poor physical health. Seekappropriate care pathway for specific guidance and refer to specialist services asappropriate, whilst continuing to provide the Universal and Universal Plus offer.
Health Visiting Service – 2-2 1/2 year Integrated Review
Other services & extra support :*Smoking cessation, * Housing* GP, * Early Intervention Team/children’s centres,* Community Mental Health Service,* Library’s * Behaviour management* Social development * Sleep *Toileting * SALT.
HV to develop a care plan and deliver evidence basedintervention in line with agreed partnershippathways.
Review within 6 weeks
Family’s goals achieved:Ensure family know how to accessthe Health Visiting Service.
Family’s goals not achieved:- Review action plan.- Seek supervision to plan next steps.- Consider referral to Children’s Social Care.
On going support from theHealth Visiting Service.
Family’s goals notachieved:� Review actionplan and goals withthe family.� Seek supervision.
Family’s goals achieved:� Ensure family knowhow to access theHealth Visiting Service.� Plan next steps withfamily or other servicesas appropriate.
Ensure appropriate safeguardinginterventions are in place to reduce risks& improve health & wellbeing of childrenfor whom there are safeguarding & childprotection concerns.
Review
HDFT SafeguardingChildren’s Policy.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYThe Health Visiting Team will develop an understanding of the breastfeeding needs of Families with Children under 5 in their Locality by:• Working jointly with Health Partners particularly GPs, Midwifery Colleagues, NYCC Children’s Centres and Voluntary Agencies to develop quality services
which support families who choose to breastfeed.• Providing and promoting access to good quality information around breastfeeding.• Informing families about Local Service Provision such as Breastfeeding Cafes; Breastfeeding Support Groups and Peer Support.• Promoting and working to the Baby Friendly Initiative Standards.
UNIVERSALEvery family will be seen antenatally and postnatally by a trained member of the Health Visiting team. Antenatal contacts will ensure that pregnant women aresupported to recognise the importance of breastfeeding and early relationship building for the health and wellbeing of their babies. Postnatal contacts willencompass discussions around the benefits and management of breastfeeding, how to respond to/recognise baby’s needs and relationship building. HealthVisitors will undertake routine breastfeeding assessments using Unicef’s Breastfeeding Assessment form at the new birth visit or where subsequent problemsarise. This will ensure issues requiring further support can be identified.
UNIVERSAL PLUSAdditional services that any family might need if there is a risk to the establishmentand continuation of breastfeeding to prevent problems developing or worsening.
UNIVERSAL PARTNERSHIP PLUSAdditional services for families where a breastfeeding issue hasbeen identified, not resolved or requires specific input.
Breastfeeding Pathway
Gain advice from BFChampions ifrequired.
Health Visitor refers to Specialist Service.Health Visitor to provide Universal and UniversalPlus offer and any action/support as agreed withother services. Other services may include:Midwifery, GP, Lactation Consultant, Paediatricians,ENT.(Actions may include use of other pathways ).
Review
Families goalsachieved.
Families goals not fully met:Review action plan with family.Refer to Infant Feeding Policy /Breastfeeding Pathway to plannext steps.
Family signposted to otherservices.
Family goals notachieved:� Review action planwith family.� Refer to Jointinfant feeding policyand BreastfeedingPathway to plan nextsteps.
Family’s goals achieved:� Ensure family knowhow to access theHealth Visiting Service.� Plan next steps withfamily or other servicesas appropriate.
1:1 or group based support
GP; Midwifery Services;Breastfeeding Counsellor;Children’s Centre Support;Breastfeeding Café; PeerSupport; Breastfeeding SupportGroup; Postnatal Groups (LocalServices may differ).
Refer to BreastfeedingSupport Group.
Named Health Visitor to work with the family.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYCorporate Health Visiting teams will help identify the key health needs affecting their population.HV teams will identify the key agencies and networks in their area.
UNIVERSALAll Children have the right to achieve and maintain an optimum standard of health and development.Each family will have access to a health needs assessment and will have a care plan with clearly identified need.All families will know how to contact their local Health Visitor and services.
UNIVERSAL PLUSUniversal Offer and any identified additional needs requiring intervention as per local procedure usingprofessional analysis and judgement.All identified needs will be covered within a care plan showing the pathway taken.Families can be discussed at Supervision either clinical or safeguarding.
UNIVERSAL PARTNERSHIP PLUSAll identified needs will be covered within acare plan showing the pathway taken.Liaise and discuss with Safeguarding Teamand/or Looked after Children’s Team asrequired. All children will be reassessedmonthly
HV Integrated Early Help and Intervention Pathway
Childrencentreactivities.
HV to write reports and attend meetings as per localprocedures. Provide on going support.Reassess progress jointly with families and otheragencies and refer accordingly.When outcomes are met return to UP or Universal.
All plans will be reassessed 4-6 weekly and pathway adjustments made where necessary.When outcomes are met families return to Universal Service. If needs increase completeCAF and coordinated child and family plan, follow to Universal Partnership Plus pathway.
Refer toappropriateHealth specialist for e.g. GP;Paediatrician;Speech Therapy;Physiotherapy;Dietetics;Audiology;Ophthalmology;IAPT.
CoreOfferParentingGroups.
Refer/signpost toappropriatenon healthspecialist foreg Advocacy ;CitizensAdvice;Housing;Povertyadvice;Relate; EarlyInterventionTeam.
Refer toChildren’sSocial Carefollowingprocedures/ pathway.
CompleteCAF/localassessmentand identifyhealthneeds.
Refer toPreventionteamfollowingprocedures.
HV interventionusing evidencebased modelsto promoteresponsiveparenting, e.g.SolihullApproach,MotivationalInterviewing,listening visits.
Referral to APfor intensivework.
CommencespecialistPathway i.e.BreastFeeding;Domesticabuse;Alcohol/Drug;Perinatalmental health..
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYThe Health Visiting Team will develop an understanding of perinatal mental health needs of Families with Children under 1 year in their Locality by:Working jointly with Health Partners, NYCC Children’s Centres and Voluntary Agencies to develop quality services which support families.Providing and promoting access to good quality information around perinatal mental health.Informing families about Local Service Provision such as Support Groups and Peer Support.Promoting awareness of cultural sensitivities and use of appropriately trained interpreters and resources.
UNIVERSALEmpower families to access the Health Visiting Service. Inform of Children’s Centre Services support groups. Encourage healthy eating and exercise. Liaisewith GP and Community Midwife. Consider history of such as ‘life stresses’.Health visiting teams will assess women's PNMH at first contact (ante-natal) plus a minimun of two additional core contacts.First line assessments should be carried out using DEPRESSION IDENTIFICATION (DIQ) Questions as per NICE guidelines ( 2014 ).In the case of anxiety consideration should be given to using the GAD2 questions. If positive response to DIQ or GAD2 consider EPDS, PHQ-9 AND GAD7.At initial, and all future contacts, include an assessment of the mother and baby relationship.When further assessment is indicated use professional judgement and recommended assessment tools for PNMH.If alcohol misuse suspected use the Alcohol Use Disorders Identification Test (NICE Guidance CG115). If drug misuse is suspected follow the recommendationson identification and assessment NICE Guideline CGS1 (please see alcohol and drugs misuse pathway)
UNIVERSAL PLUSAdditional Health Visiting Services where there is evidence or high risk of PNMHconcerns.Refer to rapid review of HCP (2015) for additional guidance (Pg 49).Liaise and coordinate support with GP/Midwife/ other professionals as needed.
UNIVERSAL PARTNERSHIP PLUSAdditional services where a PNMH issue has been identified needingexpert help or PNMH concerns are accompanied by other significantcomplex needs.Liaise and coordinate support with all health and multi-agencyprofessionals involved.
Perinatal Mental Health (PNMH) Pathway
Rapid response from HV team for families needingexpert help.Named Health Visitor will refer to GP and or specialistservices such as Crisis Team.Consider TAC, liaison with Children’s Social care.Refer to Early Intervention Pathway, PNMH Standardand Policy.
Ongoing liaison with all professionals involved.
Review action plan using initial tool of assessment.(EPDS, GAD7, PHQ9 )
Families goals achieved,follow Universal pathway.
Families goals not met. Follow UPPpathway.
Family signposted / referred toother community services.Referral to GP/CPN/IAPT asneeded.
Named Health Visitor to work with the family.6 active listening visits will be offered using shortterm guided interventions using evidence basedapproaches such as Motivational Interviewing.Solihull Approach and CBT based self help.Liaison to continue with all professionals involved.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYMembers of the Health Visiting team will work towards improving the transition to parenthood and helping parents make informed decisions that enhanceoutcomes for children and families by:* Building links with local services to improve access to provision within the community.* Ensuring families know how to access the Health Visiting service and further help and support.* Promoting and working to the Baby Friendly Initiative Standards.
UNIVERSALAll A&E attendance notifications may be recorded by Band 4 as long as a Health Visitor has signed and dated prior to scanning A&E form, within 5 days ofreceipt. Then decide appropriate action. Record in Significant Events on SystmOne and then scan the paper document onto child’s records. If the decision is tofollow up with the parents then the contact must be recorded onto SystmOne. After each 4 significant events, review with a colleague and decide if furtheraction needs to be taken.
UNIVERSAL PLUSAdditional services that the family may require if a need for extrasupport is identified.
UNIVERSAL PARTNERSHIP PLUSFamilies identified as needing additional targeted support for issues such assafeguarding, domestic abuse, mental health, poor physical health. Seekappropriate care pathway for specific guidance. Families may have beenidentified and referred on by A&E staff automatically and appropriate follow upwith take place.
Health Visiting Service – A & E Attendances
Family signposted to other services.Examples could include:• Early Intervention Team /children’s centres.
Ensure appropriate action is takenby an appropriate resource.
The Health Visiting Service will refer to specialistservices as appropriate and continue to provide theuniversal and universal plus offer and any additionalaction or support as agreed with other services.
Review
Family’s goals achieved:Ensure family know how to accessthe Health Visiting Service.
Family’s goals not achieved:- Review action plan.- Seek supervision to plan next steps.
On going support from theHealth Visiting Service.
Family’s goals notachieved:� Review action planand goals with thefamily.� Seek supervision.� Consider referral toChildren’s Social Care.
Family’s goals achieved:� Ensure family knowhow to access theHealth Visiting Service.� Plan next steps withfamily or other servicesas appropriate.
Ensure appropriate safeguardinginterventions are in place to reduce risks& improve health & wellbeing of childrenfor whom there are safeguarding & childprotection concerns
Review
HDFT SafeguardingChildren’s Policy.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYHealth Visiting team to ensure records are complete - including completion of the ‘hand over to school nursing’ ( 5-19 Health Child Team) template for allchildren.Maintain good communication with the System One team.Identify current level of care.Maintain good working relationship with 5-19 Healthy Child Team.
UNIVERSALBoth written and SystmOne records transferred onto the 5-19 Healthy Child Team caseload at the time of their 4 th birthday.Families and schools first point of contact to be the 5-19 Healthy Child team once the child has started school.End care of mother records on SystmOne if youngest child (quick action button.
UNIVERSAL PLUSFamilies that the Health Visiting Team are providingwith extra support.Timing of record transfer and handover will benegotiated in the best interest of the child.Details of support placed on the ‘hand over to schoolnursing’ template. Telephone handover to namedHealthy Child Team practitioner (record).
UNIVERSAL PARTNERSHIP PLUSFace to face hand over to named Healthy ChildPractitioner (record).Timing of records transfer and handover will benegotiated in the best interest of the child.Health Visitor to inform multiagency team name andcontact details for the Healthy Child Team to continueworking with the family.
Transfer of Health Visiting records to 5-19 Healthy Child Team
SystmOne tabbed records to be printed andsent to the Health Child Team.
Moving from area telephone handover to thenamed Healthy Child Team practitioner (record ).Records sent via safeguarding team if childprotection plan in place or LAC team if a LookedAfter Child.
Moved fromarea, new areanot usingSystmOne.
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Jane Webster - Clinical Lead Health VisitingAugust 2015
In consultation with
COMMUNITYHealth Visitors will work in partnership with other Health Visiting services to ensure the safe transfer of children and families into the local area by:Ensuring families know how to access the health visiting service, Children’s Centres and other local support services.Work closely with GP’S and other agencies such as the Children’s Centre.
UNIVERSALEnsure that all children/mothers are registered on CHIS (Child Health Information Service) who will formally request the transfer of records within 2 weeks andtask the HV Team to register family. HV will register on to 0-5 unit.Be aware of records transferring in and refer to SystmOne if required for example, records on a floppy disk.Administrator to send an introductory letter to the family within five working days of notification.Health Visitor to complete the families holistic assessment within two-four weeks (if under the age of 2 years to be completed at home). Exception to forcesfamilies – refer to local HDFT policy.All children under the age of 12 months to have a named Health Visitor.
UNIVERSAL PLUSFamilies identified as needing extra support following movement in to area.
UNIVERSAL PARTNERSHIP PLUSFamilies identified as needing additional targeted support byprevious Health Visitor.
Transfer In from Out of Area Pathway
Named Health Visitor to have direct liaison/handover with previous named Health Visitor.
Review
Family’s goals achieved:Ensure family know howto contact the HealthVisiting team
Family’s goals not achieved:� Review action plan.� Seek supervision and plan nextsteps.
Ongoing Support from HealthVisiting service.
Family’s goals notachieved:Review action plan.Seek supervision andplan next steps.
Family’s goals achieved:Ensure family know howto contact the HealthVisiting team.
Family signposted to other services.Examples may include:• Housing.• GP.• Dentist.• Children’s Centre/Early Intervention.• Local Schools.
Health Visitor to complete holistic assessment withinthe home environment within 10 working days.To identify ongoing care plan and refer to specialistservices as appropriate.
Review
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Jane Webster - Clinical Lead Health VisitingAugust 2015
