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Health Care Provider Toolkit

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 four main objectives are:

  1. To provide evidence-based and experience-informed recommendations for a standard of practice for the ambulatory clinical care of youth with chronic health conditions and/or disabilities ages 12-24 years of age.
  2. To provide a standard of documentation for the preparation and transfer to adult specialists and community-based family practitioners (physicians and nurse practitioners).
  3. To provide access to transition education, resources and services for youth, families, health care providers, and community agencies.  
  4. To provide monitoring and evaluation of system and clinical change and person-level outcomes. 

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 graphic below).  

Click to enlarge




The Transition Clinical Pathway (TCP) was developed through stakeholder engagement in pediatric, adult, and community settings. This standardized tool:

  • Offers a youth-focused approach that facilitates patient engagement
  • Increases efficiency by reducing long-hand or unnecessary documentation
  • Ensures a patient-centred approach when assessing youth and families' progression towards requirements for transfer
  • Supports early identification of those needing additional support 
  • Reduces variation amongst clinical practices
  • Provides direction for standardized processes, benchmarking, and accreditation. 

The TCP is a developmentally-appropriate measure of the youth's skills, knowledge and behaviours, initiated at 12 years of age in the pediatric setting and completed at age 24 in the adult system. 

The TCP has 3 components:

  1. Age-sensitive, developmentally-appropriate indicators for youth-focused care and transition readiness. 
  2. Summary of patient profile, including eligibility for adult services, list of adult care providers and reports and assessments required on transfer., 
  3. Youth-centered written strengths, concerns and goals on transfer.  

Transition Clinical Pathway (Simple) 

The TCP (Simple) has been developed for youth who have one chronic health condition without significant cognitive, physical or emotional special needs. The goal is for youth to be engaged in their transition planning to the best of their ability and capacity and, where needed, assisted by others. Download here.


Transition Clinical Pathway (Complex) 

The TCP (Complex) has been developed for youth who have complex health conditions including 2 or more conditions and possible cognitive, physical and emotional special needs. The goal is for youth to be engaged in their transition planning to the best of their ability and capacity and, where needed, assisted by others. Download here.

Indicators within the Transition Pathways correlate directly to the Youth Quiz and Parent & Family Checklist (integrated self-assessment tools for patients and families).  Every item on the Youth Quiz and Parent & Family Checklist is linked directly to specialized resources in the Youth Toolkit and Family Toolkit to support self-directed learning.  

YouthQuiz Pic.jpg


A comprehensive Medical Transfer Summary (MTS) was identified as a priority tool for the enhancement and assurance of appropriate and comprehensive transfer of youth with CHC/Ds. 

Through funding from the Doctors of BC Shared Care Committee, this work began in January 2012 and became available as part of BC Transcription Services’ templates for dictation in the Fall 2014. 

The Medical Transfer Summary (MTS) was developed within the Triple Aim Framework to enhance the patient/provider experience, maintain or reduce costs, and improve health outcomes. 

The goals of the MTS are to:

  • Ensure that a comprehensive medical history and plan of care accompanies every youth with chronic health conditions at the time of transfer from pediatric to adult physicians.
  • Enhance continuity of care and shared care between pediatric and adult physicians.
  • Enhance shared care between family practitioners and adult specialists.
  • Improve attachment of youth to adult care providers, especially their family practitioners.
Am I ON TRAC for Adult Care? is a youth readiness questionnaire developed in 1998 (revised in 2012) as a tool to help youth self-identify their own learning and skill needs as they prepare for the transfer to the adult health care system and adulthood. In 2012, the 25 item assessment tool was validated with 200 youth from various clinics at BC Children’s Hospital for youth 12-19 years of age with a CHC/D. The study validated the psychometric properties of the questionnaire which means that most young people in this age range (12-19 years of age) will understand and respond to the questions in consistent ways. In addition, the Am I ON TRAC - Parent Version was given to parents of the youth, comparing the level  of agreement (concordance) between the youth and parent responses. 

The study was the master’s thesis of Melissa Moynihan RN MSN, guided by Dr. Elizabeth Saewyc (PI) from the University of British Columbia School of Nursing. 
The results of the study have been presented in posters: 
  1. Concordance of youth and parent scores (Society for Adolescent Health and Medicine) 
  2. Assessing adolescent readiness to transition (International Association of Adolescent Health). 
The study has been published Moynihan, M., Saewyc, E., Whitehouse, S., Paone, M., & McPherson, G. Assessing readiness for transition from paediatric to adult health care: Revision and psychometric evaluation of the Am I ON TRAC for Adult Care Questionnaire. Journal of Advanced Nursing, 71(6), 1324-1355. DOI: 10.111/jan.12617 

The Youth Quiz is a 48 item checklist that includes the 25 knowledge and behaviour indicators that are in the validated Am I ON TRAC youth readiness questionnaire. It is posted online within the ON TRAC Youth Toolkit and is downloadable to phone, tablet, and computer.  It can be used for youth and families at every clinic visit to track areas to work on, as a companion to the overall readiness assessment. In addition, each indicator is hyperlinked to an Activity Card in the online Youth Toolkit to support youth in developing the skills or knowledge described by the indicator.  Similarly, the Parent & Family Checklist, built from the Am I ON TRAC - Parent Version, has 46 indicators that include the 25 indicators from the study also linked to Activity Cards in the Family Toolkit

Each indicator on the Youth Quiz correlates directly to indicators in the clinicians Transition Clinical Pathway (Simple) and on the Parent & Family Checklist to the Transition Clinical Pathway (Complex).   These combined tools offer a process for youth- and family-focused transition assessment, screening, intervention and evaluation.

Transition Homepage

SOURCE: Health Care Provider Toolkit ( )
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