The Top 12 Key Components of a Transitional Care Programme
The following list is based on principles detailed in " Transition: getting it right for young people" (DoH 2006) and the National Service Framework Hospital standards (DoH 2003).
1. A written transition policy which is the responsibility of a named person, is agreed by both paediatric and adult providers and covers (2- 13). For a examples of such a policy and additional resources click here.
2. Appropriate environment ["You're Welcome Quality Criteria"]
3. Consultation with users - young people and their parents ["Coming out of the shadows" document RCPCH]
4. A policy on timing of transfer which includes flexibility, developmental readiness and health status.
5. A preparation period and education programme for the young person and parent. For examples of such programmes click here
6. Identification of a key worker
7. Planning of a coordinated transfer process with the young person and their parent/guardian. For examples of tools to use in this planning eg checklists click here
8. Ensure primary care involvement and involvement of other services to meet broader and social care needs eg social services, education/vocation, youth service and key youth health-related voluntary agencies including sexual health and substance use
9. Identify interested and capable adult services
10. Provide training in transition for new staff . For training resources click here
11. Administrative Support. For examples of clinic letter template inclusive of transitional issues, transfer summaries, etc click here
12. Monitoring and "fail-safe" mechanisms. For audit tools click here