Transition Care Plans: moving from CAMHS to adult mental health services

What is a Transition Care Plan?

A Transition Care Plan (TCP) is a document that young people receiving treatment from CAMHS complete as part of their transition to adult mental health services. It gives you the chance to outline your needs, wants, preferences and concerns ahead of the move, so you can work with the main person who provides your mental health care and plan the process together.

When is a Transition Care Plan filled out?

The TCP is filled out after you and your CAMHS team have decided that it's time to start the process of transitioning into adult mental health services. The age when this happens can be different depending on your health board, but you and the people you care about should be involved in planning for the change.

Click here to download a table that lists the ages people transition to adult services in each board.

Once the transition is complete, a TCP Evaluation Document is filled out so you can provide feedback on the process.

How do I fill out a Transition Care Plan?

You can complete your TCP yourself or with your treatment team. TCPs start out with some fairly basic information about dates and contact information – you can fill this in with the help of your main point of contact at CAMHS, if needed.

Then there are a number of questions, divided into categories: Transferring to Adult Mental Health Services, Self-advocacy (Speaking Up for Myself), Health and Lifestyle, Daily Living, Independence, Leisure, and My Wellbeing. These are filled out by saying 'Yes', 'No', or 'I am unsure/I would like more information'. If you like, you can provide a response using a rating between 1 and 10, with 1 meaning 'No' and 10 meaning 'Yes'.

After these questions, you can fill out the sections called My Transition and What Else is Happening in My Life (Other Transitions). For these, you just write your answers in the boxes.

After completing the TCP, you can give it to a member of your treatment team. The TCP should be updated at different parts of your move to adult mental health services, to show where you are in your journey.

This Guidance Document has more detailed information.

Why complete a Transition Care Plan?

Completing a TCP helps young people transitioning to adult mental health services get started on thinking ahead and being in control of the move. It also allows you to express your views, opinions and concerns clearly throughout the process.

Also, the TCP allows adult mental health services to identify your individual needs and offer the right help during and after the transition, to make sure the change is as easy as possible.

These plans have been developed using a rights-based approach – this means that each patient, their views, and their rights are at the centre of all the decisions that were made about the documents.

Who sees the Transition Care Plans?

The TCP is shared with your team at young people's services, as well as your new team at adult mental health services. You should keep your own copy too. You can share your plan with anyone else you would like to be involved, like carers, your GP, social workers or anyone else who is important in your support network. Or, you can ask your main point of contact in the treatment team to do it for you.

All the information in the TCP is kept confidential – it's only shared if you give your permission, or with those who play an essential part in your care. The only exception is if a patient is thought to be a risk to themselves or to others.

For more information about your privacy as part of NHS care, click here.

Where can I find the Transition Care Plan documents?

You can read and download the TCP Document below. You can also read the Guidance Document that has more information and gives detailed instructions on filling out the TCP Document.

If you have completed a transition to adult mental health services, you can fill out the Evaluation of Your Transition Process Form and send it to your treatment teams.

If you are a professional looking for the transition planning service documents, they can be found on the Healthcare Improvement Scotland website, here.