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About the Transition Care Network

The Transition Care Network aims to improve systems and processes for young people with chronic health problems and disabilities to facilitate their effective transition from paediatric to adult health services. It also provides support and advice on transition planning for young people, their parents and health care professionals.

Health transition

As a child becomes an adult they outgrow the expertise of children’s health services and need to find adult health providers. Health professionals must discuss "transition" to prepare a young person for care in this adult setting.

Transition takes time. Clinicians and parents should start to bring up the topic of transition with young people in early adolescence so they are well prepared by the time they move to adult health services, usually between the ages of 16 to 18 years. The ACI Transition Care Network collaborates closely with Trapeze which is the chronic care and transition service of the Sydney Children's Hospitals Network to support young people, their families and health care teams.

Our People

The Transition Care Network has 3 Co-Chairs. One from a paediatric setting, one from an adult setting and one consumer. Dr Jane Ho and Lif O’Connor commenced in May 2021. The consumer co-chair is still being recruited to.

Jane Ho

Jane Ho, Co-Chair
Staff Specialist, Trapeze
Sydney Children’s Hospital Network

Lif O’Connor

Lif O’Connor, Co-Chair
Intellectual Disability Mental Health Pathway Coordinator
South Eastern Sydney Local Health District

Jane Ho is a paediatrician and adolescent doctor who works as a staff specialist at Sydney Children’s Hospitals Network. She and colleagues started Trapeze in 2013, the transition support service, and also works in the Children’s Hospital at Westmead Eating Disorder service. Jane works in private practice at Total Health Care in Bondi Junction. She is a conjoint senior lecturer at the University of Sydney and the University of New South Wales. Jane has presented and published on adolescent health and transition nationally and internationally.

Jane believes adolescents and young people are full of promise and that support and interventions that enhance their independence, self-management and transition to adult health will, to quote the Lancet Commission on Adolescent Health and Wellbeing (2016), yield a triple benefit: for today, into their adulthood, and for the next generation of children. That sounds like good value.


Lif is a registered general and mental health/intellectual disability nurse, with extensive experience working in diverse settings; paediatrics, adult renal medicine, adult ICU, adult mental health services, WA SchooI of Nursing, patient flow management and across the life span in intellectual disability. Lif has previously worked as an ACI Transition Care Coordinator for almost 6 years and during this time facilitated the establishment of transition clinics in Schools for Specific Purposes across SESLHD and ISLHD. In her current role as Intellectual Disability Mental Health Pathway Coordinator for SESLHD, Lif works with mainstream mental health services to create pathways to access for people with intellectual disability across the lifespan.

Lif is passionate about improving transition care particularly in adult settings and is currently engaged in setting up conjoint transition clinics between Child and Adolescent Mental Health and adult mental services in SESLHD.

Lif is a PokemonGo Sensei known across Sydney and parts of the US as “The legend”. If not playing PokemonGo, Lif is seriously into jig saws.


The ACI Transition Care Network is led by an Executive Committee, which includes doctors, nurses, allied health staff and consumers.

The Network has more than 200 members and includes clinicians, consumers and representatives from the NSW Ministry of Health local health districts, specialty network governed health corporations and government and non-government organisations.

Priorities

  • To collaborate with clinicians to determine numbers of young people with a range of chronic illnesses across NSW and develop optimal service models for their adult management.
  • To collaborate with local health districts and specialty network governed health corporations to establish committees to improve care for young people with chronic illnesses and disabilities.
  • To collaborate with Trapeze, the chronic care and transition service of the Sydney Children's Hospitals Network.
  • The Transition Care Coordinators:
    • work closely with medical and nursing staff to make sure all young people have a transition process in place.
    • help to sort out difficulties in finding or attending adult health services.
    • provide information about health services.
    • provide guidance to attend clinics and make sure that young people are successfully engaged in the adult health service.
    • assist young people to adjust to a new adult team and service.

The ACI Transition Care Network is led by an Executive Committee, which includes doctors, nurses, managers, allied health staff and consumers.

The Network has more than 180 members and includes clinicians, consumers and representatives from the local health districts, specialty networks, primary care and non-government organisations.

Priorities

  • To collaborate with clinicians to determine numbers of young people with a range of chronic illnesses across NSW and develop optimal service models for their adult management.
  • Improve engagement with consumers, adult health clinicians and primary care.
  • Capturing the transition experiences of consumers
  • Develop transition outcome measures and patient reported measures

Achievements

  • Publishing of Botulinum Toxin A Transition Project: Working Together: A Collaboration between Paediatric and Adult Rehabilitation Services.
  • Facilitating the establishment of the Statewide Spina Bifida Adult Resource Team (SBART).
  • Developing resources to assist young people, parents and clinicians to prepare and plan more effective transition to adult services.
  • Publishing six papers on transition since 2006 in peer reviewed journals and contributing to two texts on adolescent health.

Background

The Transition Care Network was established in December 2002 as part of the Greater Metropolitan Transition Taskforce (GMTT). The Network Manager and Transition Care Coordinators joined the network in 2004 and are committed to improving healthcare for young people across NSW.

Mae Rafraf

ACI Transition Support Worker, Western Area

Sue Towns

Department of Adolescent Medicine, SCHN

Jane Ho

Staff Specialist, Trapeze

Patrick Bolton

Redevelopment Clinical Lead, POWH

Sarah O’Connor

Outpatient Dietitian, Mona Vale Hospital

Daniela Feuerlicht

Network Manager Youth & Diversity, SCHN

James Mallows

Consumer representative

Jodie Thompson

CNC Spinal Cord Injury / Transition Coordinator, Kids Rehab, CHW

Rachael Havrlant

Acting Manager, ACI Transition Care Network

Paula Carroll

ACI Transition Care Coordinator, Western Area

Silvana Techera

ACI Transition Care Coordinator, South Eastern Region

Angie Myles

ACI Transition Care Coordinator, Northern Area

Alexis Berry

Rehabilitation Physician, Concord Rehabilitation General Hospital

Heather Burnett

Paediatric Rehabilitation Physician, Staff Specialist, HNEKidsRehab

Valsa Eapen

Chair, Infant Child and Adolescent Psychiatry, UNSW

Jo Brady

CNC Northcott, A/Team Leader, SBART

Mary Crum

ACI Paediatric Network Manager

Matthew Mallows

Consumer representative

Gideon Sandler

Head & Neck Surgeon / Surgical Oncologist / General Surgeon

(Adult & Paediatric) - Westmead Hospital & The Children's Hospital at Westmead

Clinical Lecturer, University of Sydney

Lif O’Connor

Intellectual Disability Mental Health Pathways Coordinator, SESLHD

Sarah Cullen

Consumer representative

Michael Kohn

Head of Department, Adolescent and Young Adult Medicine, Westmead Hospital

Kaye Farrell

Accredited Diabetes Educator, Transition Coordinator, Westmead

Linda Soars

Clinical Associate Director, Children and Older People Stream ACI

Transition Care Network

Contact

Rachael Havrlant
A/Manager Transition Care Network