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Transition to Adult Care

ON TRAC:
Transitioning Responsibly to Adult Care
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For YouthFor FamiliesFor Health Care ProvidersServices and Resources A-Z

Where do I start?

  1. Download and print your own Transition Timeline Brochure.
  2. Identify your strengths, and what you need to work on: 
    • Youth: take the Youth Quiz  
    • Parents: complete the Parent/Family Checklist 
    • Print copies to bring to your next clinic appointment 
    • 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   
  3. You can find all the Activity Cards in the Youth Toolkit and Family Toolkit - check out the different categories!
  4. The Youth Quiz and Parent/Family Checklist are integrated with the Transition Clinical Pathway, used by clinic staff - the items match to help you track your transition planning

Why do we need to work on transition?

The goal of transition is to offer a step by step process (starting at 12 years of age) in which care providers help youth and parents gain skills and knowledge to enter into the new adult system (by 18 years of age) prepared and ready to face new experiences.

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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 – whether they are prepared or not. 

Unprepared families tell us that ‘it is like falling off a cliff.’ 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

ON TRAC has responded to the guidance from youth, young adults, family members, medical specialists, family physicians, nurses, social workers, psychologists, physiotherapists, occupational therapists, dieticians, child life workers, administrators, and researchers across pediatric, adult and community-based services throughout BC. Over 100 agencies and 450+ individuals shared thier expertise and time - Download a complete list of our Partners & Collaborators here.

The ON TRAC Initiative has been built on the expertise of a large group of stakeholders throughout the province. Beginning with a 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 transitions youth face at 18 years of age (school, health care, home care services, insurance, and living)
What we do

 

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ON TRAC is a province-wide transition 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 directly 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 facilitate workshops and presentations for youth, families, and health care providers to increase awareness, skills, and competencies about transition issues, and share resources and research.

For information about workshops and presentations, please email Ciara McGeough at cmcgeough@phsa.ca.

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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