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Transition to Adult Care

Enabling transitions is a core practice standard. Resources are available to support the essential partnership with patients, families and all providers to support youth with special health care needs as they move from pediatric to adult health care.
Download the Transition Timeline brochure >

Continuing Professional Development Resource*

Need to learn more about why transition to adult care matters for your practice? Participate in Continuing Professional Development e-learning modules by visiting Transitioning to Adult Care

Condition-Specific Transition Care Management Plans and Resources*

Newly released! A collection of twenty-four cardiology and neurology condition specific care management plans have been developed to support providing effective care to these patients. Visit Also included on the website are resources to support practitioners with information about Transition Tips, Fee Codes, the Special Access Programme and more.

*These resources were funded by the Specialist Services Committee (partnership with Doctors of BC and the Ministry of Health).

ON TRAC model

The award-winning ON TRAC Initiative (2012-2016) was designed to affect changes in policy, clinical practice, communication, documentation and processes in order to improve outcomes for youth and families, the competencies of health providers, and overall health transfer.  


Beginning with a background document (ON TRAC Part One Overview) and the Youth and Young Adults in Transition Provincial Workshop in 2011, hosted by Child Health BC, representatives from ministries, organizations, and agencies caring for youth identified the need to integrate health transition with the many life transitions youth face at 18 years of age (education, health care, home care services, insurance, and living).  


Through further extensive stakeholder engagement, literature and program review, and research, the ON TRAC Model has been refined to include:

  • Transition Clinical Practice Guideline – to provide evidence-based and experience-informed recommendations for a standard of practice for the timing, preparation and planning, transfer, roles, and tasks to support the transition to adult care –  Transition Clinical Practice Guideline 
  • Health care provider tools to document  planning, preparation, and transfer improving communication and streamlining care across pediatric, community and adult services – Clinical Support Tools 
  • Integrated youth, family, and health care provider tools to support improved access to services and resources – Youth Toolkit and Family Toolkit 
  • Ongoing stakeholder discussions, workshops, education, and feedback mechanisms for all stakeholder groups (youth, families, and health care professionals)
  • Contributions to evidence-based practice through data collection, research, and evaluation
The ON TRAC Initiative has benefited from the collaboration and integration of multiple projects to address the number of variables and challenges faced by youth as they transition into a new system of care.

Transition Homepage


Guidelines, tools and educational materials have been developed as part of the ON TRAC Transition initiative for use within BC Children's Hospital and other partnering agencies in BC. All guidelines, tools and educational materials will undergo regular review.

Any use of these materials cannot be the responsibility of BC Children's Hospital nor can BC Children's inform other agencies directly of changes made to materials through ongoing review.

Agencies other than BC Children's may use this information. We ask that BC Children's Hospital and Child Health BC are acknowledged.

Clinical guideline

The Transition Clinical Practice Guideline was developed to facilitate the comprehensive planning, preparation, and transfer of youth with special health care needs to adult care services, ensuring youth engagement and attachment to primary care and adult services. The seven core recommendations for best practice have been developed with input from youth, families, and care providers. The guideline outlines the timing, preparation and planning, transfer requirements, roles and tasks that can be embedded into clinical care in the pediatric, community and adult settings (a shared care approach) to facilitate preparation, transfer and safe attachment in the adult system. The Guideline and tools may be used to meet Accreditation Requirements for the Transfer to Adult Care.


The Transition Clinical Practice Guideline recommendations can be integrated into practice, in part, by the use of standardized tools for youth, families, and health care providers (as outlined in the algorithm below - click to enlarge).


Clinical tools

The strength of the ON TRAC model is that tools and resources are integrated across all three groups of stakeholders: youth, families, and health care providers.  Each group has a Toolkit – including assessment tools to identify strengths and learning needs; interactive databases to support self-directed learning and skill building; and links to services and resources to increase awareness, learning, and access.

Visit the Clinical Support Tools page for more information on the following tools (including downloadable PDF versions):


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SOURCE: Transition to Adult Care ( )
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