PFCC Sandy and Kyla - Youth Transitions in Care

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PFCC Sandy and Kyla - Youth Transitions in Care

  1. 1. Youth Transitions in Care Dr. Sandy Whitehouse, MD Medical Lead, Transition Co Presentor: Kyla Brophy
  2. 2. What is Transition? Transition is a process that occurs throughout pediatric care that educates and empowers youth and their families to become active participants in their own care. It is not just the transfer of care to the adult system.Rosen D. Between Two Worlds: Bridging the cultures of child health and adult medicine. J Adolesc Health 1995;17:10-16
  3. 3. Transition is an issue for FamiliesFamilies say “they are falling off a cliff” • Disconnected from Community Care • Limited access to Family Physicians • Patients ‘lost’ or orphaned • Inefficient transfer of health care information • Services and benefits change at 18 years
  4. 4. What are the Reasons?• Youth and families not prepared• Adult system different• Do not want to leave what is familiar• Added family stress – families on the edge of coping – financial, mental health resources.• Inadequate transfer communication
  5. 5. Pediatric and Adult Care – Two Different Cultures? Pediatric Adult• Family Focused • Client Centred• Parental Involvement • Autonomy• Consent • Access to Information• Multidisciplinary • Referral based• Developmentally Oriented • Single Physician • Investigational
  6. 6. On TRAC: Transitioning RESPONSIBLY to Adult CareRESEARCH RECORDS RESOURCES
  7. 7. On TRAC: Transitioning RESPONSIBLY to Adult CareRESEARCH • RIRISK PROCESS RISK STRATIFICATION RECORDS RESOURCES COLLABORATION ENGAGEMENT YOUTH FOCUSSED
  8. 8. On TRAC: Transitioning RESPONSIBLY to Adult CareRESEARCH CONTENT CON INFORMATION T DATA WORK LOAD TOO TOOCHALLENGING RECORDS TO PROCESS IMPORTANT STRATEGY TO SUCCEED TOOLS RESOURCES IGNORE RESOURCES COLLABORATION ENGAGEMENT YOUTH FOCUSSED
  9. 9. Youth Focused Transition Planning IncludesTalking about • Self Advocacy • Independent Behaviors / Self Management • Social Supports • Educational / Vocational / Financial Planning • Sexual Health and Personal Safety
  10. 10. Draft January 2013ON TRAC Transition Target PopulationAlgorithm Youth 12-24yrs Youth 19-24yrs Youth 15-16yrs Youth 17-18yrs Youth 12-14yrs Adult Care Is Is Youth Are youth Ready systems meeting for activated indicators Transfer? for future TRAC it TickiT care? complex care Transition Triage Scale Completion of Transfer Transition Clinical Pathway for process Youth/Families with Two visits Adult care Complex/Special Needs Minimal annual visit to FP (based on Cross Ministry Protocol) receiving all reports
  11. 11. Guidelines for Youth Engagement Key to success: Authentically engaging youth as partnersthroughout every stage of the project, with equal say and a meaningful, tangible impact
  12. 12. Guidelines for Youth Engagement• Youth driven• Accessible & Inclusive • Providing transit passes, • Food, • Alternative scheduling options, • Honoraria, • Child care, • Accessible spaces (location and amenities), • Translation services• Diverse & Community-Based
  13. 13. Example 1: Youth Voice Project• 2 years, funded by Vancouver Foundation in partnership with ImpactBC• Building a provincial database of youth and youth groups/service providers• Establishing a provincial YAC (Youth Advisory Council) to engage youth with CHC/Ds as leaders in the project• Developing peer-led workshops on transition to be facilitated in community spaces and condition-specific camps• Engaging youth in a peer mentorship program to recruit future peer facilitators and YAC members
  14. 14. Example 2: Just TRAC It• Powered by PiC YAC at BCCH• Using an existing medium to engage youth in a new way – 90% of youth have access to a data phone (iPhone, Android) or tablet (iPad)• Promotional campaign to “keep your phones on” – Tasks and guideliens to track medications, tests, appointments, reminders, health information, etc.• FREE – no app necessary• Youth driven

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