Transition Planning Checklist for Disabled Children and Young People in Child, Youth and Family Care

Introduction

This checklist is to help you when you are developing a transition plan for a disabled young person. It provides information for transition planning for disabled young people who will be leaving CYF care and moving to adult health disability support services.

This checklist is for young people who meet the criteria for disability support services funded by the Ministry of Health. How to access the disability eligibility criteria is outlined later in this information. This does not include young people who have mental health issues only.

All relevant parties and agency professionals involved in the life of the disabled young person should be involved in developing a transition plan such as those mentioned in this checklist.

The key components to transition planning include:

• undertaking co-ordinated planning between CYF and other agencies and a smooth transition between services and funding arrangements
• existing care and services are reviewed to ensure needs continue to be met
• ensuring the disabled young person and the family/whānau are involved in the process and know what to expect
• ensuring permanency and stability for the child/young person 
• ensuring the interests of the young person are protected.

Please note this information has been developed to complement current social work practice and  CYF transition from care to independence processes.

Transition Planning Checklist

• Including the disabled young person and their family/whānau
• Disability assessments
• Joint agency care planning
• Involving the Needs Assessment Service Coordination (NASC) Agency
• Involving education
• Guardianship issues
• Transition planning timeframes and review.

Including the Disabled Young Person and Their Family

Involving the disabled young person and their family is good social work practice. This may require specific attention as transition planning for a disabled young person may involve a number of parties who all need to be included. Extra care should be taken to ensure the voice of the disabled young person does not get lost.

Depending on each disabled young person’s circumstances, particular attention may need to be given to communicating with the young person ie limitations with speech, behavioural triggers, intellectual disability etc.

If you as the social worker don’t feel confident about communicating with the disabled young person, you should discuss this with their family/whānau or someone close to them ie family friend or mentor. Also, the disabled young person is likely to have someone they trust and who communicates well with them such as their special needs teacher or therapist, family member etc.

Disability Assessments

It is important that the young person has an up-to-date assessment for their disability support needs. The assessment/s should clearly diagnose the young person’s disability, determine their eligibility for disability support services, and outline what the disability support needs are for the disabled young person and their carer/s.

There are two types of assessments which will be required for the disabled young person:

The first is an assessment by the Needs Assessment Service Coordination (NASC) Agency who are the gateway to disability support services in the Health sector. This assessment will determine if the young person is eligible for disability support services and if so then whether they will also be eligible for adult disability support services including independent supported living once they transition from CYF care.

The second type of assessment is for the disabled young person’s disability, such as level of intellectual disability, which is usually undertaken by a clinical psychologist, paediatrician or other health professional. It is important that this assessment is completed by a health professional that will be recognised by the Ministry of Health. If you are unsure of how to do this, your local NASC may be able to recommend someone. The NASC may also be able to recommend a suitably qualified assessor who specialises in disabled young persons assessments and their specific diagnosis and/or disability support needs.

In some instances, a specialist disability assessment may be required to help the NASC to complete an assessment for disability support services. Usually a specialist disability assessment may be provided by the appropriate health agency if the young person meets their criteria, but in some circumstances where an assessment is required urgently it may be the responsibility of CYF to facilitate and fund this. The cost of an assessment depends on the type of assessment required and the professional fees which will vary depending on the area of specialty.

Joint Agency Planning

As the social worker, it is your role to take the lead and coordinate this. The first step in effective transition planning is to develop a joint agency care plan for the disabled young person. The best way of doing this is to pull together a meeting with the disabled young person, the important people in their life (for example family/caregivers) and those agencies and community-based disability support services who have been involved with the young person and their family/whānau.

Along with you as the social worker or coordinator, the health, education and disability professionals are likely to have an ongoing relationship with the disabled child or young person so it is important they are involved in the transition planning.

The advantages to joint planning is that it helps foster positive working relationships between agencies who will both have a role during transition, and means that the adult health and disability agencies have advance notice that a young person will be transitioning so they can plan accordingly including for funding the care placement. It also provides CYF with disability expertise for each care and transition plan to complement the social work planning component and will ensure a smooth transition for the young person into adult health services.

The family or caregiver/s will know which professionals are involved with the disabled young person including which disability support services they need and/or are likely to be receiving. If this isn’t the case then the information may be available from the young person’s file. Continuity is important for the disabled young person, so ensuring the right disability supports are resumed or put in place as soon as possible is important.

Involving the NASC

For disabled young people, the key agency for disability services is your local Needs Assessment and Service Co-ordination Service (NASC). NASCs are organisations contracted to the Ministry of Health’s Health & Disability Services.  They work with disabled children and adults to identify their needs and allocate any services that are required to support them, their family or the carer they live with. They allocate Ministry of Health funded support services and assist with accessing other supports such as respite care.

If the young person has a disability as a result of an injury, then it may be ACC who is responsible for funding required services, so it’s important to check this out.

Many disabled children and young people coming into care will have documentation about their disability and what disability supports they receive, and for others it is the role of the social worker to contact the NASC and facilitate this. You should also establish a process for joint agency care planning and for transition times. A successful transition  can take up to two years so it’s important that this is begun as soon as possible or when the disabled young person turns 15 years if they will be transitioning to adult disability support services at 17 years.

Involving Education

Disabled young people are likely to be receiving special needs assistance for their school learning through the Ministry of Education, Special Education (GSE) and so should have an Individual Education Plan (IEP) in place for their educational needs and goals. The social worker and carer/s should be linked in to this process which is reviewed each six months.

There should also be a focus on planning for adult vocational, educational or employment training, including for when the young person leaves school. The most appropriate GSE professional or teacher should be included in the CYF transition planning as it should also take into account the young person’s educational and vocational goals. Work and Income may also be able to assist with this planning aspect.

Check with the school to ensure that the disabled young person is receiving all special education assistance that they are eligible for, ie ORRS funding, behaviour management interventions, and teacher aide support staffing etc.

Involving Disability Services Providers

Disabled young people are more likely to have their care provided by a disability services organisation such as IHC or IDEA Services, Spectrum Care and others as their care and disability support needs are likely to be intensive. Involving the disability services provider is essential to good transition planning as any changes, including changes to agency funding, will impact on the disability services provider.

In some instances, the disability services provider may be able to undertake care and/or transition planning as part of their contracted care placement role. The advantage for this is that the social worker or other professional will have disability expertise, can liaise between agencies, and will have a good knowledge of what is available locally for the young person in terms of adult disability support services. This should be discussed with the disability services provider as part of considering a care placement with their organisation.

Transition Planning

The only way to achieve effective transition planning is to develop a joint agency transition plan for the disabled young person. As the social worker, you have a lead role to coordinate this and plan who should be involved. The best way of doing this is to pull together a meeting with the young person, the important people in the young person’s life (for example family/caregivers) and the NASC Agency for adult disability support services in the Health sector, Special Education and/or ACC. There may also be other agencies and/or community support services involved in the disabled young person’s life so it’s important they are included as appropriate.

When CYF involvement ends, the NASC, Special Education or ACC staff will most likely have an ongoing relationship if the young person continues to have a need for disability support services, so it is important that they are centrally involved in the transition planning.

A transition plan should include the following considerations:

• care placement issues which can include: return to parents, permanent placement with whānau, shared care with another family, planned independence, or with a disability services provider,
• information about any income support that the disabled young person and their family/whānau may qualify for and how to apply for this support. There is a wide range of independent and supported living and disability supports available so it is important to talk to Work and Income colleagues about this. (See the MAP tool which is one of the quick links on the Doogle home page, for information about Work and Income disability payments such as Invalid’s Benefit or DPB: Care of the Sick and Infirm), 
• identification of transitional requirements with respect to the disabled young person’s educational and vocational services,
• determination of eligibility for ORRS (Ongoing and Reviewable Resourcing Schemes) funding from the Ministry of Education. If the young person is receiving ORRS funding when they leave school they will receive transition support services. Those with the highest needs are likely to receive up to $17,000 per year until they turn 65 years of age.

• clarity regarding the young person’s guardianship needs and how these will be met. This may include considering an application under the Protection of Personal and Property Rights Act 1988 (PPPR Act). The necessary forms can be obtained either from the Family Court itself or their website. Ensure you consult a CYF solicitor before progressing this as an option.

• a process for discontinuing CYF funding and/or services,
• identification of referral requirements to ensure that additional services are accessed (eg practical living skills such as money management, or services to address developing difficult behaviours such as sexual offending),
• documentation of dates and processes for discontinuing Child, Youth & Family funding and/or services,
• clarification as to who will monitor the plan and how it will be monitored (for example, regular case meetings, liaison with other services etc).

Guardianship Issues

Most disabled young people will be eligible to transition to adult disability support services from 17 years of age. The transition planning should include identifying if there is a suitable guardian for the disabled person once they exit CYF care. 

For some disabled young people who don’t have adequate family/whānau supports, there may be a need for CYF to have an ongoing role under a guardianship order. This should be an active guardian role which is undertaken to complement the care placement and support role of the disability service provider.  The social worker should seek legal advice from a CYF solicitor on which type of guardianship order is appropriate under the CYP&F Act 1989.

The specific role and functions of guardianship should be discussed with the disabled young person and also communicated clearly to the disability services provider. Having guardianship orders should not affect an effective transition from CYF care to adult disability support services at age 17 years and there should be agreement between agencies on how the social worker will continue to support the disabled young person.

If a disabled young person needs assistance with the protection and promotion of their personal and property rights, planning should begin for a guardian to be nominated and to seek orders under the Protection of Personal, Property and Rights Act (PPPR Act). This type of arrangement can be in place once they turn 18 years. Please refer to Family Court website (refer to the section above for the website) for more detailed information about this. Once this is in place there is no ongoing guardianship role for CYF.

Transition Planning Timeframes

Given the complexities around transition, particularly for young people with high support needs, joint planning between agencies should start when the young person turns 15 years to allow two years planning. This should assist a comprehensive plan being in place for transition and result in minimal disruption for the disabled young person.

A transition plan should then be reviewed at least every two months until the disabled young person is discharged from the Chief Executive’s care.

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