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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.

Patient 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 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.

Our People

Sue Towns

Sue Towns, Co-Chair
Head of Department, Adolescent Medicine Unit
Westmead Campus
Sydney Children’s Hospital Network
Sydney Children's Hospital Network

Mae Rafraf

Mae Rafraf, Co-Chair
Transition Support Worker
Western Area and Consumer Representative

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.


  • 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.


  • Collection of data on current service provision and gaps for more than 40 chronic childhood conditions to inform service planning.
  • 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.


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.

Transition Care Network


Rachael Havrlant
A/Manager Transition Care Network