Transition Guideline Recommendations

Last modified by Lisa Stromquist on 2016/08/10 19:36

Person Centred Recommendations

1. Transition planning is youth-focused and family-centred, inclusive of personal choice and is adaptable to the abilities and complexities of the youth’s needs.

2. Transition of youth and their families address the youth’s physical, developmental, psycho-social, mental health, educational, lifestyle, cultural and financial needs.

Clinical Recommendations

3. Transition for youth is supported by individualized planning in the paediatric and community settings, a coordinated transfer of care and secure attachment to adult services.

4. Healthcare providers engage, educate and build capacity of youth and their families regarding transition.

5. Collaborative respectful communication between stakeholders (youth, families, their natural networks, community, paediatric, primary and adult care provider(s) supports the flow of information and ensures safe, caring and effective transition. 

6. All youth have a primary care provider to support care coordination.

7. A developmentally appropriate individualized transition plan is prepared and documented in collaboration with the youth and family.

8. Paediatric and primary providers assess the youth’s readiness for adult care, identifying gaps in skills and knowledge requiring intervention. 

9. Healthcare providers and family members support youth at their appropriate developmental level to understand their chronic condition, treatment plan, and level of self-management. 

10. Care providers educate the youth and family about transfer of care, at least one year prior to transfer, encouraging them to share in the responsibility of accessing community and adult services, and if needed, provide additional navigational support. 

11. Priority for care coordination is given to youth with complex needs and their families.

12. Each transferring program is responsible to provide a comprehensive health summary at the time of referral, to the adult health care provider(s), primary care provider(s), youth and family.

13. Transfer of care to adult services includes monitoring of youth’s attachment to adult services, attendance at adult appointments in an expected time frame, ongoing communication between paediatric, primary and adult providers, and shared responsibility for management of youth with lapses in care.

System Level Recommendations

14. All services have a written policy for the provision of transition.

15. Develop efficient and accredited health information systems to support transfer of information and collaborative communication among sectors.

16. Organizations designate transition champions within their paediatric and adult settings to facilitate and evaluate transition.

17. Organizations provide ongoing transition education, training, and knowledge translation for all stakeholders.  

18. Researchers and clinicians develop a method for consistent data collection at an individual and systems level, including qualitative narratives of lived experiences and quantitative data, to be used by clinical teams, decision makers and researchers for quality improvement and evidence based practices.

19. Involve youth, young adults and families, policy and decision makers, administrators, researchers, and government agencies, to jointly identify system barriers, system enablers and future development opportunities for the responsible transitioning of youth.

Created by Lisa Stromquist on 2016/06/30 20:28