Principle 6 - Individual transition plan

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Each young person should have an individualised transition plan that focuses on all aspects of their life.

1
Individual transition plan to be developed in partnership with the young person, their family and carer from the age of 14 or as appropriate. It is a living document throughout the transition journey.
2
Transition is best led by the local transition coordinator or facilitator.
3
Make sure the young person and carer has a copy of their transition plan.
4
Make sure the general practitioner and all clinical teams have a copy or access to the plan.
5
The transition coordinator or facilitator regularly monitors, implements and revises the transition plan with the clinical team, general practitioner and the young person, their family and carers.
6
Upload the plan to the local electronic medical record (eMR) as needed.

Basically, it was we’ll give you a discharge letter and you can make your own way. Go and find the equivalent closer to home. Of course, there’s no equivalent down here. Belinda J, mother of a 19-year-old*

Measures

System and service measures

  • An individual transition plan is developed, implemented and updated regularly.
  • An individual transition plan is accessible and visible to the young person and all relevant health professionals.

Patient and consumer measures

  • The young person is involved in the development of their plan and given a copy.

Resources

From the Chronic Illness Peer Support (ChIPS) song writing workshop.

References

  • Binks JA, Barden WS, Burke TA, et al. What do we really know about the transition to adult-centered health care? A focus on cerebral palsy and spina bifida. Arch Phys Med Rehabil. 2007 Aug;88(8):1064-73. DOI: 10.1016/j.apmr.2007.04.018
  • Care Quality Commission. From the Pond to the Sea: Children’s transition to adult health services [Internet]. Glasgow, Scotland: Care Quality Commission; 2014 [cited 2022 Feb 10].
  • Gilliam PP, Ellen JM, Leonard L, et al. Transition of adolescents with HIV to adult care: characteristics and current practices of the adolescent trials network for HIV/AIDS interventions. J Assoc Nurses AIDS Care. 2011 Jul-Aug;22(4):283-94. DOI: 10.1016/j.jana.2010.04.003
  • Harris MA, Freeman KA, Duke DC. Transitioning From Pediatric to Adult Health Care: Dropping Off the Face of the Earth. American Journal of Lifestyle Medicine. 2011;5(1):85-91. DOI: 10.1177/1559827610378343
  • Hopson B, Alford EN, Zimmerman K, et al. Development of an evidence-based individualized transition plan for spina bifida. Neurosurg Focus. 2019;47(4):E17. DOI: 10.3171/2019.7.Focus19425
  • Kaufman M, Pinzon J. Transition to adult care for youth with special health care needs. Paediatr Child Health. 2007;12(9):785-93. DOI: 10.1093/pch/12.9.785
  • Machado DM, Succi RC, Turato ER. Transitioning adolescents living with HIV/AIDS to adult-oriented health care: an emerging challenge. J Pediatr (Rio J). 2010 Nov-Dec;86(6):465-72. DOI: 10.2223/jped.2048
  • Reiss J. Health care transition for emerging adults with chronic health conditions and disabilities. Pediatr Ann. 2012 Oct;41(10):429-35. DOI: 10.3928/00904481-20120924-16
  • Weissberg-Benchell J, Wolpert H, Anderson BJ. Transitioning from pediatric to adult care: a new approach to the post-adolescent young person with type 1 diabetes. Diabetes Care. 2007 Oct;30(10):2441-6. DOI: 10.2337/dc07-1249

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