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What is the challenge your project is going to address and how does it connect to your chosen theme?

Young people have different conceptions and experiences of their time in both CAMHS and AMH services. The transition process is often blurred and misunderstood amongst even professionals, with a lack of understanding about the pathways within both services.

The IMPACT  study (Northern Ireland, 2016) highlighted issues surrounding young people who require ongoing support from AMH services.  Results showed lack of engagement with adult services and numerous DNA of appointments, poor transition outcomes led to high dropout rates, unemployment, increase in involvement with criminal justice system, early unplanned pregnancies and homelessness.  The Northern Ireland Children and Young People’s Commissioning Report Speak Your Mind – Mental Health Review (2018) called for smoother flexible and young people-centred  transition between services.

This idea supports the theme ‘Building improvement capability and insights across boundaries’ as it will  build pathways to better support young people.

What does your project aim to achieve?

The Transition Passport (TP) (draft title as it will be co-produced with young people) will:

– allow  young people to track their transition journey jointly with professionals

– avoid young people having to re-tell their story and the difficulties that come with this.

– offer space for young people to express their wishes for their future

–Provide support in relation to education, comm/voluntary sector organisations, physical social & sexual health, employment and independent living skills, etc.

– information will be accessible, appropriate and person-centred

The project will be tested using the IHI Model for Improvement and will be measured through questionnaires (paper or survey monkey) to determine service user experience and quality improvement. The idea would be to trial the transition passport in paper format first and build the specification/prototype for app development.

VFM will be achieved from transfer from paper to electronic version and reach will be extensive (free to use).

How will the project be delivered?

A focus group of young people will co-produce the product for testing based on their experiences of transition. The design stage will involve carer input. The product will be tested (PDSAs) at service user appointments and during co-working arrangements between CAMHS and AMHS.  We have identified 3 possible risks associated with the project but we will manage these risks. These include young people not engaging in the project.  We do know however that young people are technologically minded and will respond creatively to this project. Staff may be resistant to the idea.  We are hosting a Regional Conversation in early October to explore the important  culture shift required to think in a more life span-focused way.  We also need to protect staff time to test the prototype. We will also continue to explore issues around data protection that may arise through the development of the digital format  toolkit, once the hard copy test has been carried out and any revisions have been made.

What and how is your project going to share learning throughout?

We will use the IHI Model for Improvement to design, explore and test the Transition Passport concept. We will use the PDSA tool to test small scale and then ramp up across individual staff, then with Teams, and then across other POC Teams and  boundaries. We will share our learning on-going and post project through local Qi fora in NI and through the Q website.  Transitions is a priority cross programmes of care (POC) issue, not just in ID CAMHS/CAMHS, including Forensic CAMHS/AMHS. We are hoping to take the learning(scale up)  into other POCs. We will identify potential engagement events to share current learning.  We will use existing Quality Improvement Programme Boards and engage with our Qi Training Team Leads to share the learning and build upon the project outcomes. Our intention is that all young people who will transition from CAMHS to AMHS will have access to the TP App.

How you can contribute

  • - Have any Q members been involved in any similar Transition projects nationally or internationally?
  • - Have any Q members been had any App development challenges?
  • - Have any Q members transferred hard copy to electronic copy - useful tips for transfer?


  1. Guest

    deborah hanna 1 year, 9 months ago

    This is a positive step towards proper co production, not just in the design of the app but also in the application of it.  Having information about the service you need, waiting times and what you can do about self-care in the interim could reduce levels of anxiety about change for young people and their families.

  2. Guest

    Alison Murphy 1 year, 9 months ago

    From an administrative viewpoint I can see this as being a very useful Tool for the transition of patients between CAMHS and AMHS.  This will ensure all patient information is available in a timely manner.

    Fabulous idea which should be rolled out as soon as possible to enable these young people to transition in a safe manner.  Definitely a much needed project for both the young people and for their families.

    Best wishes - Alison

  3. Guest

    Nicky Alexander-Locke 1 year, 9 months ago

    I think this is a great idea to help young people and their families to feel connected to their transition from camhs to adult services. We all understand this can be a difficult time for young people to manage these big changes so feeling connected via an app that can be on their phone or tablet/ computer is a great idea. Enabling them to navigate and be in control. Keeping young people and all professionals involved joined up in this process can only lead to smoother transitions and better engagement outcomes for the young people and their families.

    I can't wait to share in making use of this as a resource.


  4. Guest

    Excellent idea, and a logical step from the Impact project. it recognises the complexity of the transition process,not simply a move from service  A to service B but takes place at a time in young peoles lives when socially they are expected to now be adults and many of them still feel  emotionally much yuonger because of what they have been through. It seems to me what you are trying to achieve is to respect their growing autonomy  and yet support them in their vulnerability.

    Good luck with your bid, in my view a very worthwhile project.

    Dr Mary Short

    Consultant C&A psychiatrist Community CAMHS

  5. Guest

    Clare Gardiner 1 year, 9 months ago

    This is a fantastic, innovative idea.  Transisition is such a challenging time for our young people and this has the potential to make the process smoother and more user friendly.

  6. Guest

    Maria Sharvin 1 year, 9 months ago

    Really looking forward to the outcomes of this project which will hopefully be a tangible tool for clinicians, young people and their families that will aid a successful transition process to AMH and better outcomes in the longer term. This is so often a time of great anxiety and uncertainty for young people and families and this will allow these to be minimised and for clear plans to be formulated together in partnership and shared.  It is something that is much needed and will be valued by everyone. Wishing you all good luck in undertaking the project and you know you have our support in Belfast CAMHS in any way we can to help with it.

  7. Guest

    In these days of austerity along with relative stress about running into debt, some people balk contrary to the idea of making use of a credit card to make purchase of merchandise or perhaps pay for a vacation, preferring, instead just to rely on this tried plus trusted approach to making settlement - cash. However, if you have the cash on hand to make the purchase 100 , then, paradoxically, that is the best time for them to use the credit cards for several causes.

  8. Dear Martina,

    I’m so pleased to see an idea about transition between CAMHS and AMHS here! It’s such a crucial issue and whilst policy has started to move on, converting that political ambition into practice on the ground is very challenging. I am a CAMHS clinician and have been working for some years with 16-25 year olds in a version of a recovery college based on peer support. If I can help you in anyway or share learning then do let me know.

    Warm wishes


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