Element 1 Organizational Transition Policy

1.1 Develop an integrated care pathway that describes the steps that make up the transition process.

Integrated care pathway Integrated care pathway

The transition process is a series of action steps that are followed to complete the care transition.

Clink to Glossary of Terms Transition process Transition process

The transition process is a series of action steps that are followed to complete the care transition.

Clink to Glossary of Terms

are an important aspect of supporting youth navigating a transition in their mental health care. These pathways can help ease the transition process and provide a shared understanding of important steps and concepts for both the youth and those assisting in the transition.

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1.2 Develop an organization-specific transition policy

Work with family members/caregiversPeople who support the individual, providing emotional or physical care. to establish a policy.

Element 2: Transition Tracking and Monitoring

2.1 Establish organization-specific criteria and process for identifying youth who will be transitioning out of child and adolescent mental health services.

Integrated care pathway

When preparing youth for transition, several factors need to be considered. For instance, there may be age-dependent criteria for transitions out of child mental health services or receiving a specific psychiatric diagnosis. Other organizations may specify additional criteria, such as the number of sessions before transitioning.

Where possible, the transition identification process should start at least six months prior to the planned transition or earlier. It should include collaboration with a primary care provider, family caregiver (if appropriate), youth, and any other significant care provider. A transition plan should also be established during the initiation of the transition process.

2.2 Establish a transition flow sheet or logbook that tracks the completion of important steps as youth transition out of child and adolescent mental health services.

A transition flow sheet or logbook should be established and consistently updated to track all important steps completed to facilitate the youth's transition, such as confirming the timing of transfer, conducting readiness assessments, or identifying stakeholders involved in the youth's transition process. These logbooks support transition navigators in tracking and monitoring the ongoing process effectively.

Logbooks can also support clinical decision-making, such as determining the next steps in the youth's transition journey. Tracking enables transition navigators to observe youth retention and track progress through the transition plan, including when and who discussed each component with youth.

Significant Quote:

"This helps youth and support staff recognize barriers to the transition and clear up any errors or missteps that could happen during the process. It could help youth figure out what path best suits their transition needs while it is still in progress." — Youth

Element 3: Organizational Transition Policy

3.1 Conduct regular transition readiness assessments, and in collaboration with youth (and family members/caregivers, if appropriate) identify youth’s needs and goals; update regularly.

Assessing transition readiness (TR) is a critical first step to ensure that healthcare systems and supports are tailored to the needs of youth as they prepare to exit care. It is also crucial for promoting positive outcomes in adulthood. Regularly assessing TR enables the healthcare team to identify and address barriers to transition and optimize youth's readiness for adult healthcare systems. For example, some assessments evaluate youth’s skills for self-care and independence, and others may identify youth's knowledge of their health conditions and the ability to interact with healthcare providers effectively.

3.2 Provide youth (and their family members/caregivers, if appropriate) information about what to expect from adult mental health services.

Youth transitioning to adult mental health services can encounter profound shifts in the type of care they experience. They may need to navigate more autonomy or find new care providers. Preparing them with realistic expectations of the adult mental health system can ease this experience.

Clear communication about the differences in services is key to helping youth transition successfully. This includes ensuring they understand the change in healthcare delivery models, the roles of healthcare providers, and what constitutes success or outcomes in adult systems versus pediatric systems.

3.3 Develop individualized transition plans in collaboration with youth (and their family members/caregivers, if appropriate) a minimum of 6 months before planned transition, or as early as possible.

Youth with complex healthcare needs or developmental disabilities benefit significantly from individualized planning. This plan should include the identification of health priorities, development of skills for independence, and a clear roadmap for transitioning care to adult systems.

Element 4: Transition Planning

4.1 Identify the most responsible person to coordinate the transition process

A designated 'most responsible clinician' who is the primary contact person throughout the transition ensures continuity of care, and acts as the coordinator of the transition in care. This person may or may not be the same individual as the traditional 'most responsible provider', who is the physician or other registered health professional who is responsible for overseeing the treatment and care of the patient or client while they are receiving care within your organization. This person may be the youth's child and adolescent mental health services clinician or the organization's transition navigator.

A transition navigator is a registered health professional who has expertise in transition coordination and case management who provides short-term support (often 1–6 months) during the transition period (Cleverley et al., 2018). They work with youth (family members/caregivers, if appropriate) and members of the clinical team to identify needs post-discharge as well as goals for transfer of care. They have a strong understanding of community programs and resources and are able to work with youth to identify and connect with appropriate services, and continue to provide support and are a point of contact for the youth post-discharge and throughout the referral or access process to adult or other appropriate services. They may also provide psychoeducation and some short-term bridging therapeutic support while the youth is between services.

4.2 Identify everyone else involved in the transition and their specific role in supporting the transition process

Identify everyone else involved in the transition and their specific role in supporting the transition process (e.g., child and adolescent mental health services, adult mental health services, youth and family members/caregivers, transition navigator, primary care practitioners, etc.).

4.4 Discuss the optimal timing of transfer with youth

It is important to connect with youth well in advance to identify and prepare for a transfer in care. Optimal timing means the individuals’ clinical needs are taken into account, in particular if it may be that transitioning to a specialized service (i.e., early intervention in psychosis service) at a time earlier or later than age 18. Discussion with the youth (and family members/caregivers, if appropriate) to educate them on the reason for the timing of transfer of care is critical to ensure they understand the clinical and/or service rationale. Work with the young person to identify what resources or skills they need to be ready for the agreed upon transition time.

4.5 In collaboration with youth (and their family members/caregivers, if appropriate), complete an individualized transition plan and keep it up-to-date.

An individualized transition plan outlines the specific transition goals, support needs, and actions required to help youth transition into adult mental health services. It acts as a reference for navigators and clinicians to support youth through the transition process and ensure all their needs are met. Developing an individualized transition plan requires strong collaboration with youth, and youth should be aware of this transition plan as they undergo changes in the care they receive. As youth progress through the transition process, it is important to update this transition plan as goals and needs may continue to change.

The transition plan might include:

• Transition goals and prioritized actions
• Readiness assessment: A process of determining if youth are prepared to begin the transition process into adult mental health services.
• Clinical summary: A summary of pertinent patient information that can be used to convey the condition and journey of a patient, including relevant diagnoses or problems, treatments, medication history, and important contact information.
• Crisis plan: A predetermined plan that outlines means of support for youth who may experience a mental health crisis.

Given the challenges that may arise during the transition process, including a crisis plan as a part of the transition plan is of importance. A crisis plan represents a predetermined set of steps that can be taken to help youth during a moment of crisis. It outlines helpful information pertaining to the individual and can include warning signs, coping strategies, emergency contacts and support system as well as interventions to help the individual feel safe. Should youth find themselves in between transitions without access to resources, a crisis plan can be helpful to ensure they can access services.

Element 5: Transfer of Care

5.1 A specific meeting or case conference should be held with everyone involved in the transition to handover care.

Case Conference Warm Handover

The purpose of the meeting should be to provide an understanding of the young person's care up to this point, and their continuing care needs, and to identify the roles of everyone involved in the handover of care, based on the youth's consent. The handover meetings may include everyone previously identified as being part of the care team, such as child and adolescent mental health services, adult mental health services, and family members/caregivers if appropriate. It is important to ensure youth understand the process, have a voice in the decisions, and that they can choose how they would like to be involved.

For more information about who should be involved in this meeting, reference the discussion in components 4.1 and 4.2. "Parallel Care" and "Joint Working Meetings" may also be relevant for this component. Please see Component 4.6 for definitions.

5.2 In collaboration with youth, complete all documents in the transfer package

Complete referral letters, individualized transition plans, and clinical records. With youth's consent, send to adult mental health services and/or primary care provider and confirm receipt.

Element 6: Transfer Completion

6.1 The person most responsible for the transition contacts the youth (and family members/caregivers, if appropriate) 3 to 6 months after the last child and adolescent mental health service visit, or sooner if necessary, to confirm transfer to adult mental health services.

Most responsible person: The primary contact person who acts as the coordinator of the transition process and ensures continuity of care. This person can vary and may or may not be the same individual as the traditional “most responsible provider.”

Long-term follow-up with youth and caregivers ensures a smooth and successful transfer to adult services has occurred. This follow-up point can also be an important evaluation for the institution and can elucidate processes that might require change. It is important to ensure youth-friendly follow-up methods, such as text or email, which young people would be more likely to engage with.