Components of a transitional care programme
The following list is based on principles detailed in Transition: getting it right for young people (DH, 2006) and the National Service Framework hospital standards (DH, 2003).
- A transition coordinator who ensures delivery of effective transitional care within the service.
- A written transition policy which is the responsibility of a named person, agreed by both paediatric and adult providers and all major stakeholders including young people and parent representatives. ('How to' guide: how to develop a transition protocol 2009)
- An appropriate environment (You’re Welcome quality criteria 2011)
- Consultation with users – young people and their parents (Not just a phase - a guide to the participation of children and young people in health services 2010)
- A policy on timing of transfer which includes flexibility, developmental readiness and health status.
- A preparation period and education programme for the young person and parent. For examples of these see the models of positive practice section.
- Identification of a key worker for young people with complex conditions.
- Planning of a coordinated transfer process with the young person and their parent/guardian. For examples of planning tools see the checklist section.
- Primary care involvement.
- Links to, and when required, involvement of other services to meet broader and social care needs, eg
- social services,
- youth service
- key youth health-related voluntary agencies, including sexual health and substance use.
- Identification of interested and capable adult services.
- Training in transition for new staff. For training resources links see the training section.
- Administrative support. For examples of clinic letter template inclusive of transitional issues, transfer summaries, and so on see Transition - for health professionals.
- Monitoring and 'fail-safe' mechanisms. (Transition: moving on well 2008 (Annex 3), A transition guide for all services. Key information for professionals about the transition process for disabled young people 2007 (Appendix 6)).