Health Transition Action Plan

Complex and Continuing Physical Healthcare Team

Name: Mr BorisBuffoDOB:19 *** 199*

NHS Number: *** *** ****

The transition of Boris’shealth provision from children’s to adult orientated services is being coordinated by the complex and continuing physical healthcare team from St Luke’s hospital.

This is the latest Transition Health Action Plan, for all involved clinicians to refer to and for the GP to use as a basis once they become primarily responsible when Boris has been discharged by their Paediatrician.

Named and responsible GP:

Dr A J Bridlington

Kensington Street Health Centre (32)

Summary of medical issues:

  1. Spasticity and dystonia – total body involvement
  2. Microcephaly
  3. Learning disability
  4. Unidentified underlying neurological disorder
  5. Epilepsy (at high risk of recurrent seizures if medication stopped)
  6. Excessive drooling
  7. Overlapping toes and poor circulation affecting feet
  8. Fungal nail infection, right foot
  9. Symptoms of gastroesophageal reflux

Overall health:
Boris has complex combination of health needs and will need overall responsibility and coordination of the management of these by a named and responsible GP now discharged by Dr Jackson
Family will have to be proactive with appointments and Boris will require an annual LD health check.
Plan: June 2015 Liaise with GP re taking over, also ensure on book annual health check pathway.PlanCompleted, have discussed with GP’s and he is on LD pathway for annual health check
Plan: June 2015.Discuss Waddiloves as resource with family and refer if appropriate Have discussed with family and Matron at Waddiloves. Family and GP are aware of Waddiloves services and will refer themselves if episode of care required. On discharge (21.09.15) Boris under Physio and Podiatiry at Waddiloves.
Seizures:
Boris takes carbamazepine to manage his seizures, mum reports that he has a tendency to fall asleep after morning dose and is concerned that he arrives at school sleepy.
Plan: Discuss with Dr Jackson who has made referral (23.10.14) to Dr Verma Consultant Neurophysiologist at SLH following recent EEG, 28.1.15 – Dr Verma confirmed this still showed some activity and to continue with carbamazepine. Family aware.Plan completed
Plan: Originally discharged into care of GP, but as day Services require a seizure plan, have asked GP to refer to Bradford Epilepsy ServicePlan Completed
Personal Care/post school placement:
Boris has significant personal care needs Mum now feels she is ready to have some external help at home as she is finding it more difficult to manage – she is sole carer.
Plan: to ensure referral is made for continuing direct payments/care/phb assessment.
Social worker contacted 12.06.14 has discharged Boris but promised to ensure referral to adult team has been made. This was followed up as she did not seem confident and as no worker on system I made referral on 21/07/14. Allocated to Angela Utley (432681) Plan Completed
Plan: March 2015 To liaise with Adult Social workers re: DP and post school placement, met family with new Social Worker who has completed core assessment and is processing Direct Payments procedure. Also met family and SW with Kirstie from HFT 21.04.15 Kirstie is showing mum around potential placements and organising Boris’s attendance.Plan completed
Physiotherapy/postural management/Orthopaedic Monitoring:
Boris had apparent discomfort in hips and Right foot continues to turn outwards.
Plan accompany to orthopaedic appointments - Saw Mr Mann 15/12/14 and Mr Veysi 16/12/14, referral made to AGH rehab consultant for botulinum injections as Hamstrings apparent cause of pain. Plan completed
Boris will have future appointments with Mr Veysi
Boris had botulinum on 11.3.15 at AGH and Dr Stoppard has referred to Waddiloves physio for input after treatment.
Plan: Liaise with Waddiloves and school physio to ensure aware of treatment being given, done, April 2015 Plan completed
School will refer on to Waddiloves them as per normal process after end of term. Children’s physio have referred to LD physio at Waddiloves who will see Boris in future. Plan completed
Boris has support from wheelchair services, on visit in April mum pointed out that footrest too small, insert rubbing and covers shoddy/ill fitting, also needs tray for home.
Plan: Ensure reviewed, concerns passed to school nurse who will ensure seen at school plan completed
Mum aware that LD physio will support with this in future.
Sore/Infected toes:
Plan: Referral made to Waddiloves: 21/07/14 has attended, and has future appointments. plan completed
Continence:
Boris receives continence products and support via school nurse – leaving school in summer term 2015.
Plan: July 2015 School Nurses will refer to District Nurse Team when Boris leaves school this summer.Theyhave done so. Plan completed
Speech Therapy/Eating and Drinking :
Boris has received speech therapy advice whilst at school for communication and advice re: eating and drinking. He is able to eat a mashed diet well and drinks from a normal cup, he can put some food in his mouth independently but needs full supervision and assistance.
Plan: On discharge from school, ensure summary passed on by SALT to day services. Plan completed

Name: Mr BorisBuffo DOB: 19 Jul 1996 NHS Number: 601 269 9166

Updated 21.09.15 M Haines

Transition Health Care Coordinator – Complex and Continuing Healthcare Team

Room 352/004, Extension Block, St Luke’s Hospital, BD5 0NA

T: 01274 36 5585 M: 07956 062300 F: 01274 365127

This document, template not personBuffosed content - Author: M Haines V0.3 review date 01.03.16