Key Worker Pilot

The Key Working Function has been developed as a response to the NHS England & NHS Improvement Long Term Plan (LTP) commitment that by 2023/24, eligible children, young people and inpatients with a learning disability, autism - or both - with the most complex needs will have a designated Key Worker.

The Key Worker pilot in Birmingham and Solihull is being delivered by Barnardo’s and aims to provide dedicated key workers for children and young people with a learning disabilities and/or autism diagnosis, aged 14 – 25, who are high risk of or in crisis and at risk of admission.

The team will provide support to children, young adults and families, helping them to access the right help at the right time across complex systems.

Each key worker will have an active caseload of approximately 10 children and young people. The service will provide dedicated support to empower children and young people and adults to reach their potential.

The pilot will enable children and young people to have support when needed. The person and their key worker will co-produce a person-centred, need-based and age appropriate levelled support plan, ensuring continuity of the right services and support to meet the person's needs once key working involvement ceases.

The pilot will work on the principle of testing, learning and adapting the service, as needed.

What will a key worker do?

The key worker and the person will co-produce an individualised plan. The key worker will actively support delivery of the plan based on the following key principles:

Navigation and Coordination

  • Provide support to access the right help at the right time across complex systems particularly the transition for young people into adult life.
  • Build relationships and support coordination across the health, education, and social care, community and employment systems.
  • Identify and feedback gaps in service provision back to the system.
  • Support to navigate statutory and non-statutory services within the community.

Support at home and in the community as an alternative to admission

  • Coordinate care on behalf of the young person and their family to support community living.
  • Ensuring Personal Budgets provide identified support for the child/young person’s care.
  • Ensure appropriate adjustments for the young person are implemented based on their needs.
  • When an admission is necessary - be a point of contact and support for the family and support post-discharge planning.

Champion of Learning Disabilities and Autism

  • Support colleagues across the system to become learning disability and autism aware and provide learning disability and autism friendly services.
  • Model strategies relevant for children, young people and families with learning disabilities or autism, increasing levels of understanding.

Flexible and Person-Centred

  • Delivery of flexible, personalised, and child-centred support, to ensure the complex and often varying needs of children, young people and their families are met.
  • Provision of continuity if support with an open and revolving door to allow young people to return and reconnect with their key worker to help with de-escalation, avoid crisis and re-admission.

Independence and Empowerment

  • Support people to develop their own solutions, led by their strengths, needs, wants and aspirations.
  • Encourage young people to develop their own networks of support.
  • Provide relevant and age-appropriate and information, support, and advice to ensure that the young person can access support they want when they need it.

Support the voice of the young person and their families

  • Discuss and Escalate difficult issues where required.
  • Be a trusted person who actively listens and understands the young people and families they are supporting.
  • Challenge the system and its limitations on behalf of people and families.

When does it start?

The service will undergo a phased implementation from September 2021, with a view to being fully operational from 1 November 2021. It will run for a year until September 2022.

Who is eligible for support?

Children and young people with learning disabilities and autism, aged 14 to 25, already in hospital or in crisis and at risk of admission. They will  need to be on the dynamic support register (DSR) or an inpatient. Referrals be made via the DSR meetings and inpatient review and CETR.

How do clinicians refer someone for support?

Referrals will made by clinicians from Forward Thinking Birmingham, Solar, Birmingham Community Healthcare Trust and Coventry and Warwickshire Partnership Trust.

Other support

The NHS website can help you find additional or alternative support you might need related to mental health, including anyone seeking urgent help. Your GP can also provide guidance and onward referral to relevant organisations.

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