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Transition to Adult Care

ON TRAC:
Transitioning Responsibly to Adult Care
About
For YouthFor FamiliesFor Health Care Providers


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

 

Team Photo cropped.JPGThe 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).  

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. Condition-specific agencies and organizations and advocacy groups have provided valuable direction – see our growing list of collaborators.

Download a complete list of our Partners & Collaborators here.

The team


Kyla.jpgKyla is a passionate advocate for youth leadership, with a background in multidisciplinary research, facilitation, and social justice education in the non-profit sector.  Her work with ON TRAC has focused on collaborating with youth to develop, facilitate and lead youth-driven strategies and workshops that can be used in the hospital, community, and education settings. She has provided strong youth leadership and awareness through her involvement in material development and knowledge translation, youth-centered research, and ongoing evaluation. Kyla holds a BA (Hons) in Political Science from UBC, a Certificate in Dialogue and Civic Engagement from SFU, and an MSc in Gender (Research) from the London School of Economics.

 

Dewey1.jpgDewey has worked in the Canadian health care system at the federal, provincial and regional levels in acute care, public health and long-term care. He was the Director of Research for the Royal Commission on Health Care and Costs in BC and the Royal Commission on Workers Compensation in BC. Dewey has offered his extensive expertise in literature and policy reviews, knowledge translation studies, program and service design and evaluation of specialized services for children and youth, evaluation of public health surveillance systems, governance and guidelines for developing inter-agency information sharing agreements.

 

Sandy.jpgSandy has a diploma of Biotechnology (DiplT) from BCIT and dual degrees in Psychology (BA) and Microbiology & Immunology (BSc) from UBC. Sandy provides expertise in meeting organization, budgeting, research and ethics applications, online database development for monitoring and research, and editing.

 

Lucinda Bio pic.pngLucinda Jones is a parent representative to Partners in Care, the family voice at BC Children’s Hospital. She, her former husband, and son Hunter were also the founders of the Rare Diseases Foundation in BC. Along with many others, Lucinda has offered a strong parent’s voice over the past two years to ensure the ON TRAC Transition Initiative was youth-focused and family-centered. She has provided extensive oversight in the development of the ON TRAC “Parent & Family Tools and Resources,” and parental leadership to the clinical practice guidelines at the provincial and national levels.

 

Mary.jpgMary is the Nursing Lead for the ON TRAC Transition Initiative. With years of experience working with and learning from youth with chronic health conditions and their families, she has a personal passion to improve health care services for youth as they prepare for and reach adulthood. Mary’s commitment to the field of transition began in 1998 with the inception of the original ON TRAC framework, numerous publications, clinical work and presentations throughout North America. Her current focus of work includes: development of provincial and national transition clinical practice guidelines and tools, youth and family engagement, research of transitional practices as they relate to readiness and preparation for adult services, web and tablet applications, and communication strategies.

 

Susan.JPGSusan has focused her career on improving services and systems to support the health and well-being of youth and young adults.  She has worked in the field of adolescent health for over thirty years, much of it at Children’s Hospital Los Angeles, where as the Associate Director of the Division of Adolescent Medicine, she was responsible for program development and evaluation, community engagement and partnerships, and policy and advocacy efforts. Her current contributions to the Initiative include project development, engagement of adult and pediatric specialists, development of Transition Care Management Plans, and development of other strategies to support adult specialists and facilitate continuity of care in the adult care system.

 

Lynn.pngDr. Lynn Straatman is a pediatric and adult trained specialist in heart failure/cardiac transplantation who is currently a clinical cardiologist at the Vancouver General Hospital Cardiac Function and Cardio-oncology clinics.  Her research focus is the transition of adolescents with chronic health care conditions to the adult health care system, particularly from the adult provider perspective.  Currently, she is working on the Doctors of BC Specialist Services Committee transition project as the cardiology lead to facilitate the transition of adolescents to the adult care system while identifying the differences between the two healthcare systems.

 

SandyW.jpgDr. Sandy Whitehouse is a pediatrician, and has held leadership roles in both adolescent health and pediatric emergency medicine at BC Children’s Hospital. In these positions she gained insight into the infrastructure of health services in British Columbia, and an understanding of the importance of developing strong relationships between tertiary care and community partners. Dr. Whitehouse has expertise in outreach and expansion of partnerships through funding and project development. She has been highly successful in developing provincial partnerships and the growth and evolution of a transition model for BC.

 

Curren.jpgDr. Curren Warf is a pediatrician, Head of the Division of Adolescent Health and Medicine, and a Clinical Professor of Pediatrics at BC Children’s Hospital and the University of British Columbia Faculty of Medicine. Dr. Warf completed medical school at the University of California, Los Angeles-Drew School of Medicine and practiced at the Children’s Hospital Los Angeles until relocating to British Columbia in 2009. He has taken on a leadership role in the strategic planning for transition and supporting the ON TRAC Initiative.

 

What we do

 

What We Do Picture 1.png

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.

Our four 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.

Find out how you can book a workshop.

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.

Download our Projects Briefing Statement for more details on each area.

 

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