Examples of services

This service assists young people with chronic medical conditions and/or disabilities and their parents and carers to transition and transfer to adult care, in partnership with all RCH clinical teams and adult health services.

This transition process takes place over several years from the age of 15 and helps young people and parents to gain the necessary knowledge, skills and care coordination, to ensure a safe and supported move from the RCH to adult health services.

The service received recognition for implementing the National Safety and Quality Health Services standards.

The ACI’s Transition Care Service is a statewide care coordination service responsible for supporting young people aged between 14 and 25 years who have a chronic condition with complex needs as they move from children’s health services to adult health services.

This Sydney Children’s Hospitals Network service sees young people aged 14 to 25, who are living with a complex chronic health condition. It works directly with young people, their carers and clinicians to:

• identify transition needs
• identify support planning
• develop self-management skills in the young person
• promote engagement with general practitioners and the adult health system.

Trapeze clinicians work collaboratively with the ACI's Transition Care Service to ensure a smooth transition process for the young person and their family.

P2A is a Youth Health Service within South Western Sydney Local Health District that aims to ensure timely, appropriate and safe transition of care for young people moving from paediatric to adult medical care.

It forms part of a comprehensive patient journey for children and young adults with complex health needs aged 12 to 25 years. The service wraps around the latter part of the paediatric journey and the early part of the adult journey. It supports the patient, family and carers and the general practitioner (GP) team to achieve an effective transition into adult services.

The transition coordinator is responsible for creating the seamless transition from paediatric to adult services. They are responsible for:

• the intake of referrals
• ongoing caseload management
• care coordination of the young person in collaboration with the person's GP and relevant service providers.

The transition coordinator consults with stakeholders regarding the transition process and local support services.

This service provides clinical consultation, education, support and preventive health strategies to young people with spina bifida and similar conditions to facilitate their effective transition from paediatric to adult health services.

The SBART team is responsible for these activities.

• Facilitating access to general practitioners, spina bifida clinics and specialists, including urologists and neurosurgeons.
• Improving the young person’s ability to access equipment provision and equipment maintenance.
• Assisting in the adaptation to changes in life situation, such as pregnancy, parenthood, deterioration in mobility and changes in accommodation status and support services.
• Playing an educative role and providing information specific to the needs of the young person with spina bifida to health professionals in more generic services who may be able to provide the care closer to home.
• Developing a directory of appropriate services able to provide care, such as equipment supplies and maintenance, government benefits, continence assistance schemes and programs of aids for disabled persons.
• Improving access to respite services, identifying supported accommodation and educating new carers.

Patients aged 16 to 25 years with type 1 or 2 diabetes attend the Young Adult Diabetes Clinic in the Northern Sydney Local Health District. The clinic is multidisciplinary. It includes:

• an endocrinologist
• youth health nurse
• dietitian
• diabetes educators.

The clinic receives patients transitioning from Royal North Shore Hospital (RNSH) paediatric clinics. Young people attend one appointment with the endocrinologist at RNSH as part of the transition clinic. Their next appointment is within the young adult clinic at Mona Vale. Youth friendly resources are available. The clinic is open 12.30pm – 6.30pm to allow young people to attend after school, university or work.

There is also a similar clinic at RNSH.

This program in the Western Sydney Local Health District supports young adults aged 15 to 25 years with type 1 and 2 diabetes as they moved to the Young Adult Clinic at Westmead Hospital. During this vulnerable period, it provides a youth-centred care from a multidisciplinary team of:

• endocrinologists
• diabetes educators
• dietitians.

Care coordination is by a credentialed diabetes educator.

A long-established collaborative relationship with the adjacent paediatric service has been essential to many young people’s seamless transition to the young adult service. The model of care is a structured intervention which promotes self-efficacy and resilience in young adults by improving diabetes health outcomes and sick-day management skills.

The main components of the model are:

• direct phone access to a coordinator or diabetes educator
• late finishing afternoon clinics
• appointment reminders by SMS
• extended hours mobile phone support for sick day management to prevent emergency department presentation
• age-appropriate education and research
• support with negotiating the adult health system.

The Rheumatology Transition Clinic held at John Hunter Campus has access to a paediatric rheumatology specialist, an adult rheumatology specialist, paediatric clinical nurse consultant and a transition coordinator.

The Rheumatology Transition Clinic held at Liverpool Hospital has access to a paediatric rheumatology specialist, an adult rheumatology specialist, adult clinical nurse specialist, South Western Sydney Local Health District transition coordinator and an ACI transition care coordinator.

Inflammatory Bowel Disease (IBD) Transition Clinics held at Sydney Children’s Hospital Randwick has access to adult and paediatric IBD teams. The teams include a doctor, clinical care nurse, allied health clinician, adult IBD doctor, IBD nurse, Trapeze staff, and the ACI transition care coordinator.