Ontario's regional maternal-child health networks (“regional networks”) are working to improve the transition process for children with complex medical needs as they move from paediatric to adult care.
Poor transitions can lead to fragmented care, negative health outcomes and increased strain on the healthcare system. Recognizing this, regional networks and PCMCH are prioritizing collaborative, systemic efforts to ensure young people and their families are not left behind.
Part of a Milestones series on the regional networks, this article explores how two networks – the Toronto Maternal Child Health Network (TMCHN) and Kids Come First (KCF) – are supporting the transition process and leveraging PCMCH for support.
Identifying system gaps to improve care
To improve continuity of care for youth with complex medical needs, regional networks such as TMCHN are building more sustainable connections between the paediatric and adult healthcare providers. Recently, TMCHN partnered with the Hospital for Sick Children (SickKids)’s Transition to Adult Care (TAC) Program to support the launch and growth of a panel of adult care providers with an interest in serving transition-age youth.
The community of practice, made up of specialists in areas such as endocrinology, nephrology and neurology, meets regularly to review complex cases, identify system gaps and strengthen care pathways. “We brought adult care subspecialists together to better understand the challenges they face in accepting patients with complex medical needs and to start developing more concrete pathways,” said Mackenzie Heath, Program Manager for TMCHN. “Some youth don’t even have a service to transition to. These meetings create space to collaborate on practical, people-centred solutions.”
TMCHN's involvement has been instrumental in laying the groundwork for stronger adult care partnerships. While clinical operations are now led by the SickKids TAC Program, the regional network continues to support system-level coordination.
Connecting sectors for better transitions
In eastern Ontario, Kids Come First (KCF) is working to support higher-quality transitions of children with complex medical needs from paediatric to adult-based care by building strong partnerships across the healthcare system. The KCF approach focuses on mobilizing both paediatric and adult sector partners — including hospitals, community providers and Ontario Health Teams (OHTs) – to create smoother, more coordinated pathways to care.
“Our work is grounded in PCMCH and Health Quality Ontario’s quality standards and supported by tools like PCMCH’s CCKO Transition to Adult Care Toolkit,” said Tamara Schindeler, Project Manager at KCF. “We’re using those resources to identify priority populations, like children with complex care needs and those requiring mental health services, and then working with both paediatric and adult partners to align services, close gaps, and make transitions more predictable and supportive.”
KCF meets regularly with OHTs in the Champlain region to discuss emerging health issues, promote collaboration, and ensure youth priorities remain on the agenda. While challenges remain, such as defining roles in the adult sector and bridging service differences, the regional network is making strides by focusing on shared goals and system-wide impact.
Leveraging PCMCH resources to support the transition process
Ontario’s regional networks, including TMCHN and KCF, draw upon PCMCH’s Complex Care for Kids Ontario (CCKO) resources to support their efforts to improve the transition process. Such resources include the CCKO Youth Transition to Adult Care Toolkit, which has proven helpful as a guidance document and in discussions around care planning.
“We are using PCMCH’s transition tools, especially the CCKO resources, as a foundation for building regional models of care,” said Heath of TMCHN. “By learning from other PCMCH-supported networks, we’re exploring innovative models that ensure youth with complex needs experience more connected transitions into adult care.”
Schindeler from KCF added: “We’ve found the CCKO Toolkit from PCMCH incredibly helpful in guiding our work with complex care populations, which have been identified as a regional priority. The Toolkit is detailed and practical and gives us a strong foundation to build from.”
Looking ahead
As more children with complex medical needs reach adulthood, the importance of coordinated, family-centred transition planning continues to grow. By closing gaps in care and strengthening partnerships, Ontario’s regional networks are working to ensure a more seamless journey from paediatric to adult care. With PCMCH’s support, these networks are working to ensure that every young person receives the care they need, at every stage of life.
Are you interested in learning more about Ontario’s regional maternal-child health networks? Visit the PCMCH website for more information, including links to the different networks. Learn more about the key functions and features of the regional networks.