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).  

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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.  

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: