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).

  1. A transition coordinator who ensures delivery of effective transitional care within the service.

  2. 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)

  3. An appropriate environment (You’re Welcome quality criteria 2011)

  4. 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)

  5. A policy on timing of transfer which includes flexibility, developmental readiness and health status.

  6. A preparation period and education programme for the young person and parent. For examples of these see the models of positive practice section.

  7. Identification of a key worker for young people with complex conditions.

  8. Planning of a coordinated transfer process with the young person and their parent/guardian. For examples of planning tools see the checklist section.

  9. Primary care involvement.

  10. Links to, and when required, involvement of other services to meet broader and social care needs, eg
    • social services,
    • education/vocation,
    • youth service
    • key youth health-related voluntary agencies, including sexual health and substance use.

  11. Identification of interested and capable adult services.

  12. Training in transition for new staff. For training resources links see the training section.

  13. Administrative support. For examples of clinic letter template inclusive of transitional issues, transfer summaries, and so on see Transition - for health professionals.

  14. 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)).


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