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Transition to Adult Care

ON TRAC is a provincial Initiative to support youth and young adults with chronic health conditions and/or disabilities as they plan, prepare and transfer from pediatric to adult health care services.
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

Disclaimer

These 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. There are support systems at BC Children's that may not exist in other clinical settings, and therefore, any adoption of these materials cannot be the responsibility of BC Children's.  Any agencies other than BC Children's can use this information asking that ON TRAC from BC Childrens and Child Health BC are acknowledged. For ongoing evaluation, please notify mpaone@cw.bc.ca if any materials are being used and/or modified for the use in your practice or organization.

Clinical guideline

The Transition Clinical Practice Guideline was developed to facilitate the comprehensive planning, preparation, and transfer of youth with CHC/Ds 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 are also used to guide Accreditation Requirements for the Transfer to Adult Care.


ONTRACGuideline.jpg

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).

ONTRACAlgorithm.jpg


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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