Adolescent Transition – for Professionals
For adolescents who have a chronic condition or disability, transition is more complicated and the role of a key transition coordinator is particularly important to ensure the transition process is successful.
Adolescent transition is "a purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from child centred to adult-oriented health care systems" (Society of Adolescent Medicine 2003).
At the Women's and Children's Hospital we aim for the transition from paediatrics, through adolescence, and into adult care, to be adequately planned and implemented to ensure continuity of care.
- Provide high quality, coordinated, uninterrupted health care that is patient-centred, age and developmentally appropriate and culturally competent, flexible, responsive and comprehensive with respect to all persons involved.
- Promote skills in communication, decision-making, assertiveness and self-care, self-determination and self-advocacy.
- Enhance the adolescent's sense of control and independence.
- Provide support and guidance for the parent/carer of the adolescent.
- To maximise lifelong functioning and potential.
(McDonagh, 2003, 2005)
- A clear transition process, underpinned by formal guidelines and policies
- Early preparation for the adolescent and family – transition is a process, not an event
- Identification of a transition coordinator
- Good communication – openness, transparency and collaboration underpins good communication
- Individual transition plan which focuses on patient centred care
- Empowering, encouraging and enabling the adolescent to be self-managing
- Follow up and evaluation
(NSW Agency for Clinical Innovation, 2015)
Every adolescent with two or more teams involved in their care, should have a transition coordinator identified and allocated to them. For adolescents who have a chronic condition or disability, the transition is more complicated and the role of a key transition coordinator is particularly important to ensure the transition process is successful.
The transition lead can be the adolescent's doctor, specialist nurse or other allied health care professional. The transition coordinator must have an active role in the young person's care.
The transition coordinator's role is to have knowledge of the young person's condition and treatment and assist the adolescent to develop a transition plan. The transition coordinator will have an overseeing role in ensuring that the transition plan progresses smoothly and is kept on track. They will also be the contact person for the adolescent and their family as well as other departments for information about that young person's transition.
Individual teams will still remain responsible for implementing transition care relevant to their disciplines and areas, including identifying relevant adult services and initiating transfer to adult care.
The Transition Coordinator's role is to:
- Initiate early discussion regarding transition with the adolescent and family and provide the relevant fact sheets to the adolescent and parent/carer.
- Communicate with all the relevant teams involved in care to ensure a team approach to transition planning, arrange any multidisciplinary meetings as required.
- Support the adolescent and/or their family as they experience changes with the move to the adult system. Support young person to identify and develop any new skills and knowledge during the transition process.
- Assess the adolescent's readiness for transition and develop a Transition action plan with them and their family, with the aim of increasing capacity for self care (in conjunction with their capacity) to prepare them for adult health care services.
- Discussing with the adolescent and their family about having active and close engagement with a GP, prior to moving to adult services.
- Prepare families for a different system as adult hospitals do run differently. Ensure that teams are providing specific information about ongoing care available. If services are not clearly obvious, discussion with the family about options available and differences in the adult system need to take place.
- Follow up after all adult health care has been established, to check for any issues and to offer feedback opportunity.
Request to delay transition
Whilst there is an expectation that adolescents will transition to adult healthcare services by 18 years of age, life events and the adolescent's clinical condition need to be considered in planning the phases of transition.
Where the medical status or psychosocial circumstances justify a delayed transition to adult services, this delay requires approval by the Divisional Medical and or Nursing Director regarding the dates of commencement and likely completion of the transition to adult services.
The following document can be saved electronically, and forwarded to the relevant person for approval.
Note: when printing the following forms/documents, please ensure that they are printed colour for patient case notes.
Nurse Consultant, rehabilitation department
(08) 8161 8454