The transition to adult healthcare services is a process that begins prior to the actual transfer and does not stop once the transfer has occurred. Youth, their families, paediatric healthcare providers and adult healthcare providers all have an important role to play in the shared responsibility of patient care prior to and following the transfer of care.
The goals of planned healthcare transitions are to ensure high-quality, developmentally appropriate, psychologically sound healthcare that is continuous, comprehensive and coordinated, before and throughout the transfer of youth into the adult system. In doing so, youth and their families can learn to advocate effectively for themselves, maintain good health behaviors and use healthcare services to maintain their health and prevent secondary disability..
The Transition to Adult Healthcare Services Work Group was convened in February 2012. Its mandate was to make recommendations to the Provincial Council for Maternal and Child Health regarding a provincial approach to the transition to adult services for youth with a chronic and/or complex clinical condition including physical, developmental and/or mental health conditions. The recommendations are intended to be generic rather than organization, geography and/or condition specific so that they can be adapted to each patient, patient population, the unique characteristics of an organization and the geographic area.
TAHS Discharge Planning Implementation (DPI) Tool
This tool is intended as a guide for providers so they can successfully prepare patients and families to transition from youth to adult health services. The DPI Tool offers a guide on what to do and when to do it to better prepare youth and their families to receive care in adult settings.
When a More Intense Approach to Transition is Indicated
A listing of possible approaches that could be used when a more intense approach to transition is indicated.
Guidelines for Transition from Paediatric to Adult Care
The Transplant Centre at The Hospital for Sick Children developed “Guidelines for Transition from Paediatric to Adult Care”, a checklist for health care providers to use to make sure all steps are covered regarding preparing youth/families for the transition/transfer to adult care.
Readiness Checklist for Patients Readiness Checklist for Parents
The Good 2 Go Transition Program at the Hospital for Sick Children developed 2 questionnaires (“Readiness Checklist for Patients”, “Readiness Checklist for Parents”) to determine transition readiness for patients and for parents.
Inventory of Youth Transition Resources and Tools
An inventory of youth transition tools and resources, including supporting evidence, that were reviewed by members of the expert panel.
Shared Management Model of Transition
The Shared Management Model of Transition is a planned systematic approach to a gradual shift in responsibilities from the health care provider and parents to the young person, as developmentally appropriate. Preparation (e.g. attaining knowledge and assuming responsibility for health care needs) must start as early on in the child/family’s involvement with the healthcare system as is deemed appropriate, well before the formal transition process commences.
TAHS Work Group Recommendations That Have Clinical Applicability
The following recommendations and associated documents/resources/tools have clinical applicability for paediatric and adult healthcare providers in helping youth and their families who will be, or have already been, transitioned to adult services. To download the associated resources and tools, click on the links below.