How the Transition Care Service can help

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Young people with complex transition needs can use our Transition Care Service for practical help.

The two ACI-based coordinators cover most areas across NSW and the ACT. They work closely with the Sydney Children's Hospitals Network’s Trapeze Service and Transition Coordinators based in Hunter New England Local Health District and South Western Sydney Local Health District. Ask your service if they have a staff member who is able to help with your transition.

The service can:

Support plans for a transition from children's to adult health services.

Empower the young person to adjust to new services, attend healthcare appointments and take on more responsibility for their own care.

Support families helping their young person transition.

Are you transitioning to adult healthcare services?

This flyer will provide more information on how the service will support young people aged 14 to 25 who are moving to adult healthcare services.

Download the flyer (PDF 706.9 KB)

Also available as:

Who can refer

  • A young person with chronic health conditions (14-25 years) who:
    • lives in NSW or the ACT, and
    • has a chronic health condition or disability (excluding a primary diagnosis of mental health conditions) that needs complex case coordination to transition to adult specialist health services.
  • The young person’s family or carer.
  • Healthcare professionals in NSW caring for the young person.
  • School teachers, case workers and others who support the young person.

Should you refer to the ACI Transition Care Service?

Is the young person actively accessing services from Sydney Children’s Hospital Network?

Consider referring to Trapeze transition service.

Does the young person meet any of the ACI Transition Care Service’s exclusion criteria?

  • Under 14 years of age
  • Over 25 years of age
  • Have a primary diagnosis of a mental health condition
  • Have a clear transition pathway
  • Have already transitioned
  • Does not consent to ACI Transition Care Service involvement

The young person does not meet Transition Care Service referral criteria.

Consider seeking GP input or paediatric clinician-led transition care and review available transition care resources.

Which of the following groups of considerations are present?

Medical complexity
  • More than 3 specialities involved
  • Multiple comorbidities including mental health conditions
  • High medical needs
  • Medications requiring approvals or special access
Psychosocial indicators
  • Navigating complex social circumstances (eg housing, family dynamics, financial pressure)
  • Experiencing social isolation or living in rural or remote areas
  • Identifies with a community requiring culturally responsive, person-centred support
Barriers
  • Unclear transition pathways
  • Difficulty accessing or attending services
  • The young person or family needs support to engage with adult health services during transition

Select groups of considerations that are present:

If medical complexity is present

Submit a referral to the ACI Transition Care Service. Our team will review and be in touch to discuss next steps.

If medical complexity is not present

Contact an ACI Transition Care Service Coordinator for help to work out the most appropriate next steps.

View as a flow chart

Download the flow chart for printing (PDF 108.6 KB)

How to refer

Request a referral to the service by completing the referral form and submit it to your local Transition Care Coordinator.

Use the Transition Care Service map to see your referral region.

Email: ACI-TransitionCare@health.nsw.gov.au (ACI Transition Care Coordinator)

Phone: 0425 232 128 or 0484 331 242

  • Sydney Local Health District
  • Western Sydney Local Health District
  • Northern Sydney Local Health District
  • South Eastern Sydney Local Health District
  • Nepean Blue Mountains Local Health District
  • Western NSW Local Health District
  • Far West NSW Local Health District
  • Illawarra Shoalhaven Local Health District
  • Murrumbidgee Local Health District
  • Southern NSW Local Health District
  • St Vincent's Health Network
  • ACT Health

Email Angela.Myles@health.nsw.gov.au (Hunter New England Transition Care Coordinator) or phone 0434 361 202.

  • Hunter New England Local Health District
  • Central Coast Local Health District
  • Mid North Coast Local Health District
  • Northern NSW Local Health District

Renee Jones (Paediatric to Adult Transition Facilitator)

Primary and Community Health, South Western Sydney Local Health District

Mobile: 0436 812 628

Email: swslhd-p2ateam@health.nsw.gov.au

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