Information for young people transitioning from paediatric to adult health services

Most young people with a chronic condition or disability who are treated at a children’s (paediatric) hospital will eventually need to be transferred to an adult healthcare service. The process that supports this transfer is called ‘transition’. Adolescent transition helps you to understand the transition process and work towards greater independence and ownership of your health care to the best of your ability. 

The transition process starts early, as soon as you enter adolescence. You will be given the opportunity to develop skills and knowledge to enable you to successfully navigate your health in the new adult service.

Adolescent transition is:

• A developmental process that you will have an active role in. Your readiness will be determined through setting goals and using a healthcare skills checklist
• A coordinated process that involves your healthcare teams at The Royal Children’s Hospital (RCH), your transition lead, your parents/carers and most importantly, yourself. This team will help you to develop a transition plan which you can work on
• A meaningful process that should ideally occur before your final year at school
• A planned process that takes into consideration the transfer plan from each of your care team/s at the RCH and in your community, and the best timing for your transfer depending on what else is going on for you both with your health and in your life generally
• An important process that aims to prepare you for a successful transition to an adult healthcare setting

Aims of transition

These include:

• Providing high quality healthcare which is appropriate for your age, culture and development. This is individualised, flexible, responsive and relevant to your needs
• Helping you to develop skills in communication, decision-making, assertiveness, self-care and self-advocacy
• Empowering you to be more independent with your healthcare to the best of your ability and having a greater sense of control over the process
• Maximising your capacity to live well and to achieve your goals (educational, vocational, social) regardless of your health condition or disability
• Providing support and guidance for your parents/carers

What does transition mean for you?

Transition is an important process as you progress into adulthood and start taking greater ownership over your healthcare. This process will provide you with practical assistance and guidance to help prepare you for the move to adult healthcare. Discussions may include:

• Knowing what to expect with the transfer process and your role within this
• Knowing what systems or supports are available to you 
• How to become more independent with your healthcare to the best of your ability 
• Putting in place practical measures such as establishing links with a good General Practitioner (GP) in your community or investigating funding options
• Exploring your choice of adult service providers (in consultation with your medical team/s)
• Addressing potential differences in adult health services and changes in processes and expectations
• Developing confidence in the new medical team/s and in the transition process

Transition phases

There are four general phases for an effective transition process.

Introductory/Planning Phase (12–15 years approximately)

You will be introduced to the concept of transition and establish your knowledge of your medical condition and how to manage it, as you start becoming more independent with your healthcare. Transfer may seem a long while away but it’s important to start thinking about what differences you might expect in adult healthcare and how you can start working towards being ready.

Preparation Phase (15–18 years approximately)

You will develop a transition plan and be assigned a transition lead (person who will help to manage the transition process). During this phase, confidentiality, rights and self-advocacy will be explored and you may:

• Start having time in appointments with your doctor/s without your parent/carer
• Have the opportunity to meet your new adult care provider/s prior to transfer, either informally or within a combined transition clinic with your RCH and adult care team/s
• Develop greater knowledge of the options available to you 
• Further refine the transition plan and goals within this
• Receive correspondence from the RCH directly addressed to you

Transfer Phase (18–19 years)

Your readiness to transfer will be assessed and all relevant information will be sent to your new adult care team/s.
You will receive a copy of this letter too. You may have
your last visit with your RCH team/s and will start having appointments at the new adult health service/s. 

Evaluation Phase (6–18 months following transfer)

You have the opportunity to provide us with feedback about the transition and transfer process and your experience. This helps us to improve the process.