Transition Care Resources

These resources relate to systems and processes for young people with chronic health problems and disabilities to facilitate their effective transition from paediatric to adult health services.

Building Bridges to Adult Care Through Collaboration

A new transition model of care for young people with Spina Bifida in NSW Australia' was presented on behalf of the Transition Care Network, Spina Bifida Collaborative paper and Spina Bifida Adult Resource Team (SBART) at the 5th Transition Conference hosted by Bloorview Kids Rehab in Toronto Canada May 31-1 June 2010

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/155767/building_bridges.pdf

Format: PDF File (1.2 MB) Alternate Content: --

Subcategory: Spina Bifida Resource Type: Presentations

Added: 29 June 2011 Updated: 13 February 2012

Spina Bifida Checklists

Three checklists which recommend actions during and outside of clinic visitsfor young people of different age groups with spina bifida

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/155713/checklist_spina_bifida.pdf

Format: PDF File (48.1 KB) Alternate Content: --

Subcategory: Spina Bifida Resource Type: Checklists

Added: 29 June 2011 Updated: 13 February 2012

Final Report – Evaluation of the Adult Spina Bifida Resource Team 2011-2014

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/274260/Final_SBART_evaluation_report.pdf

Format: PDF File (763.7 KB) Alternate Content: --

Subcategory: Spina Bifida Resource Type: Reports

Added: 12 June 2015 Updated: 12 June 2015

Final Report on Illawarra Transition Project

Report on the project in the Illawarra region to improve the transition care for young people with Spina Bifida

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/155743/illawarra_project_report.pdf

Format: PDF File (36.4 KB) Alternate Content: --

Subcategory: Spina Bifida Resource Type: Reports

Added: 29 June 2011 Updated: 13 February 2012

Checklist for Diabetes

Checklist for young people with type 1 diabetes to review their knowledge of the disease before leaving paediatric services.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155701/checklist_diabetes.pdf

Format: PDF File (23.3 KB) Alternate Content: --

Subcategory: Diabetes Resource Type: Checklists

Added: 29 June 2011 Updated: 13 February 2012

Transition Care Network for Young People With Chronic Childhood Illnesses/Disabilities Framework

The purpose of this document is to assist all stakeholders involved in the process of transition to manage this group of young people with chronic childhood illnesses through transition, to achieve successful health outcomes and enhanced quality of life for young people and their carers/families.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/155719/ACI-Transition-Framework.pdf

Format: PDF File (544.5 KB) Alternate Content: --

Subcategory: Chronic illness Resource Type: Frameworks

Added: 29 June 2011 Updated: 13 February 2012

GMCT, Transition Care Forum 2009 - Presentation by Kirrily Rodgers

Presentation about young people with chronic illness at the Prince of Wales Hospital, given by Kirrily Rodgers at the Transition Care Forum, 17 February 2009

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/153597/rodgers_2009.pdf

Format: PDF File (274.1 KB) Alternate Content: --

Subcategory: Chronic illness Resource Type: Presentations

Added: 29 June 2011 Updated: 13 February 2012

GMCT Transition Care Workforce Project Report

Report on the project to identify service gaps and determine specific medical, nursing and allied health workforce required to manage young people with chronic diseases / disabilities transitioning to the adult health system.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/153615/transition_care_workforce_report.pdf

Format: PDF File (1.4 MB) Alternate Content: --

Subcategory: Workforce Resource Type: Reports

Added: 29 June 2011 Updated: 13 February 2012

Hunter Region Neurology Transition Project

Report on project to improve continuity of care for young people with a neurological condition as they transition to adult care

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/155749/hunter_neurology_report.pdf

Format: PDF File (70.9 KB) Alternate Content: --

Subcategory: Neurology Resource Type: Reports

Added: 29 June 2011 Updated: 13 February 2012

2015/2016 Transition Publications

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/329494/2016_Transition_Network_publications.pdf

Format: PDF File (114.4 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Clinician Summaries

Added: 6 September 2016 Updated: 6 September 2016

Generic Referral Form

https://aci.health.nsw.gov.au/__data/assets/word_doc/0009/165870/2017-ACI-Referral-Form.docx

Format: MS Word Document (112.2 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Other

Added: 31 May 2012 Updated: 31 May 2012

Australian Clearing House for Youth Studies (ACYS)

ACYS aims to support youth organisations youth workers youth researchers and young people themselves as well as policymakers researchers and practitioners in other sectors working with youth.

http://www.acys.info

Format: Webpage

Subcategory: General Information and References Resource Type: External Links

Added: 9 July 2014 Updated: 25 July 2014

Information for Professionals on Transition from Children’s Health Services to Adult Services

Introduction to transition services for health professionals, includes definitions, contacts and checklists.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0005/164246/Information-for-health-professionals.pdf

Format: PDF File (215.3 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Clinician Summaries

Added: 15 March 2012 Updated: 15 March 2012

Information for Parents and Carers about Transition from Children’s Health Services to Adult Services

An overview of transition services and guidelines for patients and carers

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/164245/Information-for-parents.pdf

Format: PDF File (315.6 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Consumer Information

Added: 15 March 2012 Updated: 15 March 2012

Information for Young People about Transition from Children’s Health Services to Adult Health Services

Guide for young people in health care covering transition services, their responsibilities, finance and education

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/164244/Information-for-young-people.pdf

Format: PDF File (683.5 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Consumer Information

Added: 15 March 2012 Updated: 15 March 2012

Overview - Parents Forum

Report on the forum for parents of young people with a disability/chronic illness held September 2005.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/155755/parents_forum.pdf

Format: PDF File (36.3 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Reports

Added: 29 June 2011 Updated: 13 February 2012

Transition of Young People with a Chronic Health Condition to Adult Health Services: Position Statement

Position statement by the Australian Physiotherapy Association

http://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/Advocacy/PositionStatement_2014_TransitionCare2.pdf

Format: PDF File

Subcategory: General Information and References Resource Type: External Links

Added: 14 July 2014 Updated: 25 July 2014

Transition Forum

Report on the forum for young people with chronic disease / disability, held April 2005.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/155761/transition_forum_abridged.pdf

Format: PDF File (172.0 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Reports

Added: 29 June 2011 Updated: 13 February 2012

References on Transition

List of references about the transition of young people with chronic illness / disability moving from paediatric to adult services

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/163156/transition_references_dec_2009.pdf

Format: PDF File (272.5 KB) Alternate Content: --

Subcategory: General Information and References Resource Type: Factsheets

Added: 15 February 2012 Updated: 15 February 2012

Transition planning checklist for young people with chronic gastrointestinal conditions

Checklist for health professionals to use with young people with a chronic gastrointestinal condition

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/155707/checklist_gastrointestinal.pdf

Format: PDF File (70.3 KB) Alternate Content: --

Subcategory: Planning Resource Type: Checklists

Added: 29 June 2011 Updated: 13 February 2012

Transition planning checklists

A series of checklists for health professionals to consider transition issues for young people with chronic illness / disability moving from paediatric to adult services

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/159915/checklist_health_prof.pdf

Format: PDF File (415.4 KB) Alternate Content: --

Subcategory: Planning Resource Type: Checklists

Added: 22 November 2011 Updated: 13 February 2012

Individual transition care plan

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0008/284435/Transition_Plan.pdf

Format: PDF File (900.0 KB) Alternate Content: --

Subcategory: Planning Resource Type: Checklists

Added: 25 September 2015 Updated: 25 September 2015

Livewire: website of the Starlight foundation especially for young people

Livewire: website of the Starlight foundation especially for young people. This website connects teens with chronic illnesses and disabilities throughout Australia

http://www.livewire.org.au

Format: Webpage

Subcategory: Patient experience Resource Type: External Links

Added: 9 July 2014 Updated: 25 July 2014

Patient’s transition experiences

View videos on the transition experiences of young people and parents/carers on the Trapeze website and check out their blogs

http://www.trapeze.org.au/

Format: Webpage

Subcategory: Patient experience Resource Type: Web Resources

Added: 25 September 2015 Updated: 25 September 2015

Teenagers with chronic conditions: transition to adult care

This video looks at the transition from paediatric health care to adult health care. Health professionals as well as parents of teenagers with chronic illness talk about the transition process. Two young people share their experiences of the move from child-centred care to adult-centred care.

http://raisingchildren.net.au/articles/teenagers_chronic_health_conditions_adult_care.html

Format: Webpage

Subcategory: Patient experience Resource Type: Web Resources

Added: 4 December 2015 Updated: 4 December 2015

Transition Video: Bringing in the Voices

This video was filmed as part of a workshop held at Luna Park in 2005 that brought young people together to help develop a transition program for young people with a chronic illness / disability as part of the Greater Metropolitan Transition Taskforce’s (GMCT) Transition Care Network. GMCT evolved to the Agency of Clinical Innovation in 2010. The Transition Network continues to improve transition systems and processes for young people across NSW and the key messages in this video are still current.

http://www.trapeze.org.au/content/our-history

Format: Webpage

Subcategory: Patient experience Resource Type: External Links

Added: 30 November 2015 Updated: 30 November 2015

Transition Checklist for Young People withCystic Fibrosis

Checklist for health professionals to use when planning transition services for young people with cystic fibrosis

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/155695/checklist_cystic_fibrosis.pdf

Format: PDF File (42.9 KB) Alternate Content: --

Subcategory: Cystic fibrosis Resource Type: Checklists

Added: 29 June 2011 Updated: 13 February 2012

Aboriginal Resources & Pathways Project: Cultural Proficiency in Service Delivery for Aboriginal People with a Disability

http://www.idfnsw.org.au/images/A_Guide_to_Cultural_Proficiency_in_Service_Delivery_for_Aboriginal_People_-_Information.pdf

Format: PDF File

Subcategory: Aboriginal people Resource Type: External Links

Added: 19 July 2016 Updated: 19 July 2016

ReachOut.com

Reachout.com is an online youth mental health service

http://au.reachout.com/

Format: Webpage

Subcategory: Mental health / intellectual disability Resource Type: External Links

Added: 9 July 2014 Updated: 25 July 2014

ReachOut.com Professionals

Content, tools and technology for professionals supporting youth mental health and wellbeing.

http://au.professionals.reachout.com/

Format: Webpage

Subcategory: Mental health / intellectual disability Resource Type: External Links

Added: 14 July 2014 Updated: 25 July 2014

Transition For Children With Intellectual Disabilities

This UK link provides an overview of transition for young people with intellectual disabilities as they move from children’s to adult services.

http://www.intellectualdisability.info/life-stages/articles/transition-for-children-with-intellectual-disabilities

Format: Webpage

Subcategory: Mental health / intellectual disability Resource Type: External Links

Added: 29 July 2016 Updated: 29 July 2016

Key Principles for Transition of Young People from Paediatric to Adult Health Care

Evidenced based best practice key transition principles for clinicians

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0011/251696/Key_Principles_for_Transition.pdf

Format: PDF File (3.7 MB) Alternate Content: --

Subcategory: Principles Resource Type: Key Principles

Added: 8 December 2014 Updated: 8 December 2014

Key Principles of Care for Young People Transitioning to Adult Health Services [summary]

Summary of evidence based best practice transition principles

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/251697/Key_Principles_of_Transition_Care.pdf

Format: PDF File (976.3 KB) Alternate Content: Plain Text

Subcategory: Principles Resource Type: Key Principles

Added: 8 December 2014 Updated: 8 December 2014

Queensland Paediatric Rehabilitation Service Transition: A Guide for parents, carers and families

This document provides an overview of transition and relevant resources and services to support young people with a brain injury to transition from paediatric to adult healthcare in Queensland. This guide has been developed by the Queensland Paediatric Rehabilitation Service at the Royal Children’s Hospital, Brisbane with funding supplied by the Motor Vehicle Accident Insurance Commission.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0011/280946/CHQ_QPRS_Transition_Guide_FAMILIES.pdf

Format: PDF File (357.5 KB) Alternate Content: --

Subcategory: Brain injury Resource Type: Consumer Information

Added: 20 August 2015 Updated: 20 August 2015

The Next Step Tookit. Transition from Children’s services to the adult world

The Next Step is a resource for workers working with young people with Traumatic Brain Injury transitioning from children’s services to adult services.

http://www.tbistafftraining.info/ToolkitA/S_0.html

Format: Webpage

Subcategory: Brain injury Resource Type: External Links

Added: 20 August 2015 Updated: 20 August 2015

Checklist for clinical care

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/284431/Checklist_for_Clinical_Care.pdf

Format: PDF File (148.2 KB) Alternate Content: --

Subcategory: Checklists Resource Type: Checklists

Added: 25 September 2015 Updated: 25 September 2015

Checklist for clinicians

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0005/284432/Checklist_for_clinicians.pdf

Format: PDF File (167.9 KB) Alternate Content: --

Subcategory: Checklists Resource Type: Checklists

Added: 25 September 2015 Updated: 25 September 2015

Checklist for family

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/284433/Checklist_for_family.pdf

Format: PDF File (289.0 KB) Alternate Content: --

Subcategory: Checklists Resource Type: Checklists

Added: 25 September 2015 Updated: 25 September 2015

Checklist for young people

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/284434/Checklist_for_young_people.pdf

Format: PDF File (181.6 KB) Alternate Content: --

Subcategory: Checklists Resource Type: Checklists

Added: 25 September 2015 Updated: 25 September 2015

Individual transition care plan

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0008/284435/Transition_Plan.pdf

Format: PDF File (900.0 KB) Alternate Content: --

Subcategory: Checklists Resource Type: Checklists

Added: 25 September 2015 Updated: 25 September 2015

Transition readiness checklist

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/284436/Transition_Readiness_Checklist.pdf

Format: PDF File (669.1 KB) Alternate Content: --

Subcategory: Checklists Resource Type: Checklists

Added: 25 September 2015 Updated: 25 September 2015

10 - Practical Tips For Health Professionals

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/284430/10_PracticalTipsForHealthProfessionals.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

1 - Transition… It’s All About Growing Up and Moving On

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/284421/1_TransitionItsAllAboutGrowingUpAndMovingOn.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

2 - How to prepare for your transition

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/284422/2_HowToPrepareForYourTransition.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

3 - Finding a Good GP

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0005/284423/3_FindingAGoodGP.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

4 - Questions Young People Ask Themselves To Find a Good GP

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/284424/4_QuestionsYoungPeopleAskThemselvesToFindAGoodGP.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

5 - Ideas For Parents/Carers to Support Young People with Chronic Conditions

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/284425/5_IdeasForParents-Carer.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

6 - Taking Charge of Your Health Care

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0008/284426/6_TakingChargeOfYourHealthCare.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

7 - Financial Issues in Adult Health Services

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/284427/7_FinancialIssuesInTheAdultHealthServices.pdf

Format: PDF File (1.1 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

8 - What Young People Have Said About Adult Hospitals

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/284428/8_WhatYoungPeopleHaveSaidAboutAdultHospitals.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

9 - Stages of Transition

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0011/284429/9_StagesOfTransition.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Factsheets Resource Type: Factsheets

Added: 25 September 2015 Updated: 25 September 2015

Feedback from the e-health symposium

A workshop 'More than just a tickbox, Engaging Young People in Health Service Delivery' was held at the Patient Experience Symposium, Australian Technology Park, Thursday 5 May 2016. The workshop was a joint collaborative between Trapeze and the ACI Transition Network and included a knowledge café that explored:

Strategies for engaging young people in health services
How do you work out what is a good website or app?
What challenges facing services when implementing social media and building e-platforms that are relevant to young people?
How can we use e-health to assess and manage psychosocial risk factors for young people?

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0005/308813/Feedback_e-health_symposium.pdf

Format: PDF File (95.6 KB) Alternate Content: --

Subcategory: Reports Resource Type: Reports

Added: 16 May 2016 Updated: 16 May 2016

Summary of referrals 2011-2015

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/299446/Summary_of_Referrals_2011-2015.pdf

Format: PDF File (60.2 KB) Alternate Content: --

Subcategory: Reports Resource Type: Reports

Added: 3 March 2016 Updated: 3 March 2016

Access Study 3

The NSW Youth Health Access Survey is a research project from the University of Sydney to find out more about how young people aged 12 to 24 access health services in NSW. Funded by the Office of Kids and Families, NSW Health, to inform youth health policy, the ACCESS 3 research study will describe the experiences of young people accessing and navigating the health system in NSW, focusing on the barriers and facilitators to accessing health care for marginalised young people in NSW. The study will focus on young people aged 12-24 living in NSW who are:

Aboriginal and/or Torres Strait Islander
living in rural/remote areas
homeless or at risk of homelessness
refugee or vulnerable migrants
identifying as gender or sexuality diverse

Research findings will be presented to key stakeholders from policy and practice to help translate the findings into policy-relevant recommendations. Visit here for more information: NSW Youth Health Access Survey.

http://sydney.edu.au/medicine/general-practice/access/

Format: Webpage

Subcategory: Research Resource Type: External Links

Added: 3 March 2016 Updated: 3 March 2016

Young people with urinary incontinence - Health professional guide

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/404793/ACI_0024_PISCES_Health_professional_guide.pdf

Format: PDF File (455.9 KB) Alternate Content: --

Subcategory: Urinary Incontinence Resource Type: Other

Added: 26 February 2018 Updated: 26 February 2018

PISCES Patient experience report

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/421896/ACI_0024c-PISCES_Patient-experience-report-A4_FINAL.pdf

Format: PDF File (1.5 MB) Alternate Content: --

Subcategory: Urinary Incontinence Resource Type: Other

Added: 15 May 2018 Updated: 15 May 2018

PISCES Project overview

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/421897/ACI_0024d-PISCES_Project-overview-A4_FINAL-1505.pdf

Format: PDF File (628.8 KB) Alternate Content: --

Subcategory: Urinary Incontinence Resource Type: Other

Added: 15 May 2018 Updated: 15 May 2018

PISCES Telehealth guide

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0005/421898/ACI_0024d-PISCES_Telehealth-guide-A4_FINAL-1505.pdf

Format: PDF File (1.7 MB) Alternate Content: --

Subcategory: Urinary Incontinence Resource Type: Other

Added: 15 May 2018 Updated: 15 May 2018

Young people with urinary incontinence - Data evaluation report

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0008/406169/PISCES_Data-evaluation-report-ACI_0024.pdf

Format: PDF File (1.6 MB) Alternate Content: --

Subcategory: Urinary Incontinence Resource Type: Other

Added: 6 March 2018 Updated: 6 March 2018

Young people with urinary incontinence

https://aci.health.nsw.gov.au/resources/urology/young-people-with-urinary-incontinence/young-people-with-urinary-incontinence

Format: Webpage

Subcategory: Urinary Incontinence Resource Type: Clinician Summaries

Added: 18 July 2016 Updated: 18 July 2016

Preparation for transition checklist for parents/carers of a young person with an intellectual disability

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0020/390035/TRP4211-Checklist-template_FA.PDF

Format: PDF File (1.1 MB) Alternate Content: --

Subcategory: Intellectual Disability Resource Type: Toolkits

Added: 1 November 2017 Updated: 1 November 2017

Transition – intellectual disability

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/390036/TRP4211-Information-sheet-template_FA.PDF

Format: PDF File (2.4 MB) Alternate Content: --

Subcategory: Intellectual Disability Resource Type: Brochures

Added: 1 November 2017 Updated: 1 November 2017

Transition Care Network

Contact

Vanessa Evans
Manager Transition Care Network

+61 2 +61 2 9464 4602

vanessa.evans@health.nsw.gov.au