Transition to Adult Care

The goal of transition to adult care is to support youth with special health care needs and their families or caregivers to gain the confidence, skills and knowledge to be ready to enter the adult health care system.

About

For youth
For families
For health care providers Services and resources A-Z

Where do I start?

Download and print your own Transition Timeline Brochure.
Identify your strengths, and what you need to work on:

Youth: take the Youth Quiz.
Parents: complete the Parent/Family Checklist.
Not sure about an item? Click on it, and it will open an interactive Activity Card with tips, videos, and resources to help you find the information you need.

Print copies and bring your questions to your next clinic appointment. Ask to discuss transition to adult care planning and your needs with your health care professionals.

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Learn more

Children and youth diagnosed with a chronic condition and/or disability in BC are most often referred to a pediatrician in the community and then referred for pediatric sub-specialty care at BC Children’s Hospital or other pediatric clinics in the province.

The multi-disciplinary team taking care of them may include physicians, nurses, social workers, dieticians, psychologists, or physical and occupational therapists. In most cases the child, parents and family members come to BCCH (or a pediatric clinic) at least once a year, more commonly 2-3 times per year, for health monitoring, tests, teaching, and support. In many ways, the pediatric team becomes a significant support system to them.

These children might have any number of conditions: diabetes, gastrointestinal disorders, epilepsy, kidney disease, arthritis, or more complex conditions like neuromuscular diseases, cystic fibrosis, cardiac diseases. Some may have more than one chronic disease or disability.

At 18 years of age, they age-out of a number of services that have supported them since childhood: school, insurance, home care, travel benefits, and many others. Additionally, they also graduate from pediatric care into the adult health care system.

The ON TRAC model and tools have been developed to help youth, families, and care providers prepare for the changes that occur in adulthood, and the differences to expect as they transfer and participate in the adult health care system.

You are not alone in this transition. Explore the Youth Toolkit and Family Toolkit to find the information and resources you need as you enter into this next phase.

Who we are

All of your care providers (in your community and at BC Children's) are part of the team who will support you to graduate from the pediatric health care system into the adult health care system. Who are the most important members of the team? You and your family.

What we do

Transition to adult care is part of the care that all health care providers at BCCH provide. Your care providers will work with you to prepare you for the adult health care system. Here's what you can expect:

1. Partnership with patients and families

2. Engagement in early and ongoing transition care

3. Individualized transition care planning

4. Collaboration and communication

5. Comprehensive health summary for the transfer of care

6. Confirmation of attachment to adult care providers

ON TRAC is an initiative with the goal of supporting youth with chronic health conditions and/or disabilities as they transition from pediatric to adult health care services.

Main areas of work include:

1. Clinical support

We work with health care professionals in the pediatric and adult systems to help ensure a smooth transfer from pediatric to adult health care services, including developing clinical guidelines and preparation and transfer documentation tools.

2. Youth and family engagement

We work with youth and families to ensure that their voices are heard in developing toolkits and resources to support their transition.

3. Education and knowledge translation

We can support workshops and presentations for youth, families, and health care providers to increase awareness, skills, and competencies about transition issues, and share resources and research.

4. Research and evaluation

We contribute to practice- and evidence-based knowledge by publishing our research and working with other programs that are evaluating transition efforts.

For a description of past projects, download the Projects Briefing Statement for more details.

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Provincial Health Services Authority