Principle 6 - Individual transition plan

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Each young person should have an individualised documented transition plan that focuses on all aspects of their life. This could include a formal transition plan template, documentation in medical records or a clinical report of discussions.

1
The individual transition plan is to be developed in partnership with the young person and their family and carer. A formal transition plan 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, family and carer has a copy of their transition plan.
4
Make sure the general practitioner and all relevant clinical teams have a copy or access to the transition plan.
5
The transition coordinator or facilitator regularly monitors, implements and revises the transition plan with the clinical team or clinician, 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

  • Transition plan template. A comprehensive document and sections that are not relevant to the young person can be easily removed. This template is particularly useful when transitioning to multiple health services.
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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