Transitional Care Team

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Contact information

Email

TransitionalCareTeam@mpft.nhs.uk

Lilac background and text that reads 'Transitional Care Team: here to help you move forward'. Three arrows point to the right.

Introducing the Transitional Care Team

When it’s time for a young person to move to Adult Mental Health Services, research shows that poor transition experiences can negatively impact mental health. At Midlands Partnership University NHS Foundation Trust (MPFT), we recognise the importance of a seamless transition for young people aged 16-25. The Transitional Care Team places young people at the centre of their care decisions, ensuring they are supported through every stage of their journey.

We aim to reduce the gaps between Child & Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS). By acknowledging the differences in how these services work and communicating between teams, we ensure smooth and well-supported transitions.

Our Approach

The Transitional Care Team provides a wraparound, holistic service, ensuring young people’s mental health, emotional, and social needs are all addressed. By placing the young person at the centre of their care, we strive for positive, high quality and safe mental health recovery.

The young person has control over their transition plan and usually develops it alongside their CAMHS practitioner. This plan provides their support network and professionals with a clear, tailored plan to transfer as smoothly as possible between services.

The Thrive Guide

Once a young person meets the Transitional Care Team, they will begin working on their Thrive Guide. This document is designed to support the transition from children's to adult services.

To ensure the Thrive Guide is relevant and effective for young adults, it has been created with input from service users who have lived experience.

The front cover of The Thrive Guide booklet

Our Team

The Transitional Care Team is made up of:

This is the person who directs the activities of the team, making sure that everyone is delivering the promise to young people*. They ensure your voice is heard, and that you are leading decisions about your care plan. *The promise to young people is made in the CAMHS service user and carer charter.

The pathway lead also makes sure clinicians are all working together to meet your needs. They also work behind the scenes to enhance and develop services for young people at MPFT. Oversees the transition team, develops processes and coordinates between teams.

Our STAR workers are here to provide support to young people during the transition to adult mental health services. They will ensure that the transition process meets the individual needs and preferences of each young person.

STAR workers will offer regular check-ins, help with mental health recovery, and connect young people with community resources, helpful apps, and activities that promote emotional and mental health regulation. They collaborate with other services to address important areas of life, such as housing, education, and more.

If young people are transitioning to a service like Talking Therapies or returning to their GP, STAR workers can assist with introductions to these services (if desired), ensuring that they have the support needed to navigate these transitions smoothly. Their goal is to ensure that young people don’t feel alone in accessing additional support and that they have the assistance they need every step of the way.

Just like the young people we serve; our Peer Support Workers have lived experience of using mental health services. They understand firsthand the worries and anxieties that may come with moving to or accessing new mental health services.

The peer support team will offer direct support by sharing their personal experiences. We hope this helps young people see that mental health recovery and wellness are possible, empowering them to work toward achieving this for themselves.

Together, the team works closely with the young person, CAMHS clinicians, AMHS teams, and parents/carers to ensure the young person’s goals are met and the transfer is smooth and effective.

Recommended Resources for Young People

We stay involved with the young person from the beginning of their transition through to the completion, and even provide short-term follow-up support to ensure they have settled into AMHS. This helps minimise the risk of disengagement from services after the transition.

We recommend a variety of resources that can help along the way:

Our Services

We offer low-level support to promote mental health and well-being during the transition, including:

Care Navigation: Assisting with access to appropriate community services.
Motivational Support: Encouraging engagement with activities that enhance well-being.
Social Engagement: Helping young people connect with social activities and peers.
Self-Care Strategies: Empowering young people to develop and use mental health self-care techniques.

Mental Health and Emotional Well-being Outreach:

In addition to our work with young people transitioning services we offer targeted support for Care Leavers and University Students around mental health management.

Join us for a drop-in session on the 1st Wednesday of every month at The Science Centre, Staffordshire University, Stoke Campus, Leek Road, Stoke-on-Trent, Staffordshire, ST4 2DF

Support for Carers

We understand that the transition period can be an anxious time for parents, carers, and supporters, especially with concerns about the young person's readiness or how they will cope with the changes.

To help those involved in the young person's mental health recovery, we offer optional parent/carer support. This is separate from the work being done with the young person and is confidential.

Our support can help manage concerns about the transition, prepare for adulthood, and explore ways to enhance support for the young person. A member of the Transitional Care Team will reach out to offer support at the start of the process.

Parent/carer support will end once the young person is under adult services, but we will continue to assist the young person as they settle in. If a parent/carer/supporter needs ongoing support, we can recommend additional resources or other mental health services.

We are here to listen and support you throughout the transition process.

A generated image of a signpost which points to the right and text reads 'Adult Mental Health Service'

For more information or to get in touch, please contact us:

E-mail: TransitionalCareTeam@mpft.nhs.uk

The Transitional Care Team: Supporting You Through Every Step of Your Journey.

Helpline and Support Services Information

If you ever feel unable to keep yourself safe due to your mental health, please call NHS 111 (Option 2) 

The 111 service will put you in touch with the most suitable crisis service for your needs and location.  

Mental Health Helpline: 0808 800 2234 – 7pm-2am weekdays and 2pm-2am weekends 
MIND Info line: 0300 123 3393 Text: 86463 9am-6pm weekdays  
Samaritans: 08457 909090 – 24hours 
No Panic: 08449674848 – 10am-10pm  
HOPElineUK (under 35 only) Call: 0800 068 41 41 Text: 07786209697   
Staffordshire Mental Health Helpline: 0808 800 2234 Text: 07860 022821 (FREE)     
E-mail: Staffordshire.helpline@brighter-futures.org.uk Instant Messaging Service (online chat): Go to the homepage (on the Brighter Futures website), scroll down and click on the instant messaging section.      
 Papyrus: Text: 07860039967 Email: pat@papyrus-uk.org 
 SANELine: 0300 304 7000  - 6pm - 11pm every day     
 Everyone Health: 0333 005 0095 (Weight management, social Isolation and Loneliness, stopping smoking, physical activity, NHS health checks, falls prevention, healthy workplaces and making every contact count).  
The Wellbeing and Recovery College Tel: 01785 221257 E-mail: wellbeingrec@mpft.nhs.uk  
The Wellbeing and Recovery College provides recovery-focused education courses that are accessible to everyone in our local communities. We work together to create an environment of hope, control and opportunity for us all.

 Mental Health Websites for Young People: 

 The Sandbox by Mindler – The Sandbox is an innovative mental healthcare service for children and young people The Sandbox | Digital Mental Health Service 
 Young minds – Mental Health Charity for children and young people.  Supporting parents. Changing attitudes. Empowering young people.  Visit the YoungMinds website.

Transitional Care Team

On this page…

Contact information

Email

Introducing the Transitional Care Team

Our Approach

The Thrive Guide

Our Team

Young People's Mental Health Pathway Lead

Supporting Transition and Adulthood Readiness Workers (STAR)

Peer Support Workers

Recommended Resources for Young People

Our Services

Mental Health and Emotional Well-being Outreach:

Support for Carers

Helpline and Support Services Information

Support is also available from these external organisations:

Mental Health Websites for Young People:

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