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On Wednesday, April 27, 2022, in partnership with the Provincial Council for Maternal and Child Health (PCMCH), Ontario Health hosted a webinar on the new Transitions From Youth to Adult Health Care Services quality standard entitled “Changing the Story: Improving Transitions from Youth to Adult Health Care.”
Geared toward 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), the webinar featured the following speakers:
Speakers provided an overview of data on how transitions from youth to adult health care services affect young people’s health care outcomes and introduced the six quality statements from the quality standard. The panelists then shared 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 health care providers who support them. A robust question and answer period followed.
View the webinar here.Passcode: 7ZH2%mKQ
Question and Answer
With the help of the expertise from our speakers, we are sharing the answers to the questions we received during the webinar. If you have any additional questions, comment below or you can email firstname.lastname@example.org.
1. What essential steps/tasks should health professionals complete to help support the client during transition of services?
Health care professionals should strive to incorporate the practices outlined in the six quality statements into their transition process, namely:
2. When does transition planning start?
Transition planning should begin as early as possible (see Quality Statement 1: Early Identification and Transition Readiness, page 11). “As early as possible” is defined as follows: “No specific age is recommended, as the optimal timing to start transition planning will depend on the young person’s circumstances. Transition planning may start as early as young childhood, 10 or more years before age 18. It can begin whenever the young person, their provider, and/or parents or caregivers identify that a transition to adult care will likely be necessary due to the nature of their health condition or disability.”
3. Are there targeted populations for which transition planning is most effective?
The scope of this quality standard includes all clinical populations, including young people with disabilities or special health care needs such as those with chronic and/or complex physical, intellectual, or developmental conditions and/or with mental illness and substance use. See page 1, “Scope of This Quality Standard,” for more details on scope.
4. Who should be responsible for transitioning youth to adult services?
Young people who will be transitioning from youth to adult health care services should have a designated most responsible provider for the transition process. The designated most responsible provider is one person from among the young person’s health care team who agrees to take on the role of coordinating the transition to adult services. This provider is identified early on and may change over time, given that the transition process is often prolonged. The young person (and their parents and caregivers, where appropriate) helps decide who this provider will be. In some instances, it may be a nurse, social worker, youth worker, or primary care provider. In other instances, this provider may have a job title such as “transition navigator,” “transition lead,” “transition coordinator,” “transition worker,” or “case manager.” See Quality Statement 4: Coordinated Transition (page 27) for more details.
5. What is the process for formally handing over the young person’s care from the pediatric to adult provider?
Quality statements 1 to 6 of the Transitions From Youth to Adult Heath Care Services quality standard outline a process for handing over a young person’s care from youth to adult health care services. Of note, the section “What This Quality Statement Means” for organizations and health services planners (Quality Statement 3: Transition Plan, pages 25–26) includes the following details:
Ensure that youth-oriented and adult services have systems, processes, and resources in place to
Similarly, the section “What This Quality Statement Means” for clinicians includes specific details for health care providers (see page 25).
6. How can health care providers better incorporate the voices of young people and caregivers into transition planning?
Each quality statement in the Transitions From Youth to Adult Health Care Services quality standard emphasizes the importance of working collaboratively with young people and their caregivers, and treating them as respected members of the young person’s health care team. For example:
See also Appendix 4: Values and Guiding Principles, which includes the following guiding principle of care:
7. What are your best-practice guidelines?
Key clinical guideline sources used to inform development of the quality standard included:
8. Where can I find current data related to the transition from youth to adult health care services and related outcomes?
Data related to the transition from youth to adult health care services is included in the “Why This Quality Standard is Needed” section of the quality standard (page 5) and in the Case for Improvement slide deck available on the Transitions From Youth To Adult Health Care Services quality standard resources page
9. How do things like funding for private services, access to health services, and mental health services change when a young person turns 18 years of age?
The quality standard does not specifically address each of these areas, but does point to some resources on these topics:
Questions Related to Resources
10. Where can I find resources to help parents and caregivers?
Please refer to the Resources for Young People and Their Caregivers on the Transitions From Youth to Adult Health Care Services quality standard webpage to find links to helpful information, videos, and toolkits to support parents and caregivers of young people going through the transition process.
11. What resources are there to support young people with mental health and/or substance use issues during the transition to adult health care services?
The Canadian Mental Health Association’s webpage on Transitioning from Youth to Adult Mental Health Services provides an overview of what this transition is like and lists resources to support this transition. The Service Transition Plan: Moving to Adult Mental Health and Addiction Services, co-designed by young people for young people, is a transition plan to help young people, their families, and care providers prepare for their move into mental health and addiction services for adults.
12. Which smartphone applications are recommended to assist teens in managing their own care?
The MyTransition App version 2.0, developed by CanChild and McMaster University, is designed to help young people between the ages of 12 to 18 years begin taking charge of their health care as they approach adulthood. Available to download for free on Apple and Android devices, MyTransition App’s key features include:
Alternatively, the Just TRAC it! Video by BC Children’s Hospital teaches young people how to use their smartphone’s built-in apps to manage their health care.
Please see the Resources for Young People and Their Caregivers to find additional tools and resources to support young people and their caregivers during the transition from youth to adult health care services.
13. Are there any resources to help with designing transition program for youth with type 1 diabetes? Heart transplant?
The key areas for improvement outlined in the six quality statements are applicable to a broad population, and therefore would apply to young people with type 1 diabetes or to those who have had a heart transplant, and any transition program designed for them should incorporate these elements. As the scope of the Transitions From Youth to Adult Health Care Services quality standard includes all clinical populations, condition-specific resources were not compiled as part of its development; however, the BC Children’s Hospital Transition to Adult Care website includes the following clinical support tools for young people with type 1 diabetes and transplants that might be useful as an example:
Questions about Access to Primary Care or Specialist Care
14. Do you have any recommendations on how to find a primary care provider who will accept the young person as a patient?
Here are two resources that may be helpful in finding a primary care provider:
15. Do you have any recommendations on how to manage long waitlists for specialists?
The quality standard does not specifically address how to manage waitlists. However, there is relevant information within the quality statements and/or the supporting definitions and rationale sections. For example:
16. Questions Related to Funding, Policy, and Programs
What changes to funding, policy or programming will occur as the result of the Transitions From Youth to Adult Health Care Services quality standard? (This question is an amalgam of several queries on whether additional funds, health human resources, or programs would be implemented to support care as described in the quality standard).
The purpose of this quality standard is to describe high-quality care for young people who are transitioning from youth to adult health care services (and their parents and caregivers). The quality standard does not directly make recommendations for funding, policy, or programs; however, the quality standard may be used as a tool to help advocate for programs, funding, or models of care. The Quality Standards Program has recently developed an implementation framework and strategy that captures the common opportunities that will enable system uptake of the quality standards and will take action to deliver on high-impact priorities over the next 2 years.
You may also be interested in:
View the Quality Standards Webinar Library for other past webinars on various topics.