Youth Transitions in Care Dr. Sandy Whitehouse, MD

Medical Lead, Transition

Co Presentor:

Kyla Brophy

What is Transition?

Transition is a process that occurs

throughout pediatric care that educates

and empowers youth and their families to

become active participants in their own

care. It is not just the transfer of care to

the adult system.

Rosen D. Between Two Worlds: Bridging the cultures of child health and adult medicine. J Adolesc Health

1995;17:10-16

Transition is an issue for Families

Families say “they are falling off a cliff”

• Disconnected from Community Care

• Limited access to Family Physicians

• Patients ‘lost’ or orphaned

• Inefficient transfer of health care information

• Services and benefits change at 18 years

• .

What are the Reasons? • Youth and families not

prepared

• Adult system different

• Do not want to leave what is familiar

• Added family stress – families on the edge of coping – financial, mental health resources.

• Inadequate transfer communication

Pediatric and Adult Care – Two

Different Cultures?

Pediatric

• Family Focused

• Parental Involvement

• Consent

• Multidisciplinary

• Developmentally Oriented

Adult

• Client Centred

• Autonomy

• Access to Information

• Referral based

• Single Physician

• Investigational

On TRAC: Transitioning

RESPONSIBLY to Adult Care

RECORDS

RESOURCES

RESEARCH

On TRAC: Transitioning

RESPONSIBLY to Adult Care

• RIRISK

RECORDS

RESOURCES

RESEARCH

PROCESS

COLLABORATION

ENGAGEMENT

YOUTH FOCUSSED

RISK STRATIFICATION

On TRAC: Transitioning

RESPONSIBLY to Adult Care

RECORDS

RESOURCES

RESEARCH CON

T

CONTENT INFORMATION

DATA

WORK LOAD

PROCESS STRATEGY

TOOLS

RESOURCES

COLLABORATION

ENGAGEMENT

YOUTH FOCUSSED

TOO

CHALLENGING

TO

SUCCEED

TOO

IMPORTANT

TO

IGNORE

Youth Focused Transition

Planning Includes

Talking about

• Self Advocacy

• Independent Behaviors / Self Management

• Social Supports

• Educational / Vocational / Financial Planning

• Sexual Health and Personal Safety

ON TRAC Transition

Algorithm

Target Population

Youth 12-24yrs

Youth 12-14yrs

Youth 15-16yrs

Youth 17-18yrs

Youth 19-24yrs

Adult Care

Transition Clinical Pathway for

Youth/Families with

Complex/Special Needs

(based on Cross Ministry Protocol)

Completion of Transfer

process

Two visits Adult care

Minimal annual visit to FP

receiving all reports

Is

youth

meeting

indicators

TRAC it

Is Youth

Ready

for

Transfer?

TickiT

Are

systems

activated

for future

care?

complex care

Transition

Triage

Scale

Draft January 2013

Guidelines for Youth

Engagement

Key to success:

Authentically engaging youth as partners

throughout every stage of the project, with

equal say and a meaningful, tangible

impact

Guidelines for Youth

Engagement • Youth driven

• Accessible & Inclusive • Providing transit passes,

• Food,

• Alternative scheduling options,

• Honoraria,

• Child care,

• Accessible spaces (location and amenities),

• Translation services

• Diverse & Community-Based

Example 1:

Youth Voice Project

• 2 years, funded by Vancouver Foundation in partnership

with ImpactBC

• Building a provincial database of youth and youth

groups/service providers

• Establishing a provincial YAC (Youth Advisory Council)

to engage youth with CHC/Ds as leaders in the project

• Developing peer-led workshops on transition to be

facilitated in community spaces and condition-specific

camps

• Engaging youth in a peer mentorship program to recruit

future peer facilitators and YAC members

Example 2:

Just TRAC It

• Powered by PiC YAC at BCCH

• Using an existing medium to

engage youth in a new way

– 90% of youth have access to a

data phone (iPhone, Android) or

tablet (iPad)

• Promotional campaign to

“keep your phones on”

– Tasks and guideliens to track

medications, tests, appointments,

reminders, health information, etc.

• FREE – no app necessary

• Youth driven