The transition to adult-oriented healthcare services for youth with a chronic and/or complex physical, developmental and/or mental health condition 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, and 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, when appropriate, 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.
PCMCH’s resources and tools support a provincial approach to the transition of youth to adult-oriented services. These resources are generic rather than organization-, geography- and/or health condition-specific, so that they can be adapted for each person, patient population, organization and geographic location.
The recommendations and associated documents/resources/tools below 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.
Developed by PCMCH in 2022, the Complex Care for Kids Ontario (CCKO) Youth Transition to Adult Care Toolkit outlines the process for children and youth with medical complexity (CYMC) transitioning from the CCKO Program to Ontario’s adult care system.
On April 27, 2022, PCMCH and Ontario Health hosted “Changing the Story: Improving Transitions from Youth to Adult Health Care,” a webinar for those involved in the delivery of care to young people who will transition out of youth-oriented health care services and into adult health care services, including health care providers, managers, administrative leaders, and young people and their parents and caregivers.
Co-hosted by Sanober Diaz, Executive Director of PCMCH, Dr. Kristin Cleverley of the Centre for Addiction and Mental Health, and Dr. Alene Toulany of the Hospital for Sick Children, this webinar featured panelists with lived experience and clinical experience sharing their insights on how implementing the Transitions From Youth to Adult Health Care Services quality standard will improve the transition process for young people, their parents and caregivers, and the healthcare providers who support them.
If you missed the webinar or would like to watch it again, please click here and use access code 7ZH2%mKQ
Questions and answers from the webinar are available here.
In addition to the above resources, PCMCH partnered with Ontario Health to assemble an advisory committee comprised of young people and caregivers, and clinical leaders from a broad range of sectors to develop the Transitions From Youth to Adult Health Care Services quality standard. Drawing on evidence from clinical guidelines and expert consensus, this quality standard includes six quality statements that address areas with high potential to improve transitions to adult care for young people in Ontario, including: early identification and transition readiness, information-sharing and support, the transition plan, coordinated transitions, introduction to adult services, and transfer completion.
The Transitions From Youth to Adult Health Care Services quality standard can be used to help patients, families, and caregivers know what to ask for in their care; to help health care professionals know what care they should be offering, based on evidence and expert consensus; and to help health care organizations measure, assess, and improve their performance in caring for patients.
- 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
- PDN Transition to Adult Care Working Group Recommendations Report
