Transitions health facilitator for Middlesbrough: Hilary Webb
Flatts Lane Centre
Transitions health facilitator for Redcar and Cleveland: Barbara Milsom
Learning disability community
South Flatts Lane Centre
Who do we work with?
We work with young people, with a learning disability, aged 14 -25 and aim to help the transition from children’s to adult services run smoothly
How do we do this?
Transitions nurses follow a Public Health Model of Care (Dahalgren and Whitehead).
- We offer planned support.
- We support transition – We try to be proactive and seek to identify young people who may need support as they move into adult services. We do this by ensuring other professionals and agencies are aware of our role and what we do. We attend educational reviews and transitions events and offer support directly to young people and their families.
- We provide health support – We complete a comprehensive health needs assessment. This is used to identify a young person’s health needs and allows us to start to get to know the young person. Using the information we develop a health action plan, hospital passport and professionals report towards the Education Health and care plan.
- We facilitate – We spend time developing contacts and networks with individuals and services that could support young people through transitions. We try and ensure that young people and their families have the right people involved to support transition and their wider health needs as they move into adult services.
Many aspects of life can affect your health, including work, education, housing and social or community networks. Transitions nurses are not responsible for addressing problems you have with these, but will consider how these affect you in their care planning.
If you are in crisis, or need additional support following a crisis, this will be given by child and adolescent mental health services (CAMHS) or the wider adult learning disability team.
If there are any unmet health needs we would either look to promote contact with appropriate agencies to meet these needs or provide support ourselves.
How can you refer to us?
Anyone can refer to us. Referrals can be made:
- by telephone (unpaid carers or people with learning disabilities only)
- a referral form
- or on your behalf by your care co-ordinator.
L484, V5, 23/01/2023 (Archive: 23/01/2026)