Transition

RCH > Nursing Services > Transition to adult health services

For RCH Health Professionals

Contents of this webpage:

This webpage outlines the transition policy, process and principles of a successful transition. There are resources available to assist you in the transition process and transfer of your patients to an adult health care service.

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RCH transition policy
Why do we need to transfer young people at all?
Preparing patients for the adult health care system and their own self management
Principles of transition
How do I transition and transfer my patients to adult health care?
Accelerated Care in Emergency (ACE) patients and transition/ transfer to adult health care
Adult clinics available in adult health services
All useful transition and transfer documents

On the right is a picture of our award winning desk top flip chart that is situated on RCH outpatient clinic desks. It is designed to guide hospital staff through the transition process specifying the tasks and things to consider at different age groups for your patients. Further copies are available.

Other hospitals both nationally and internationally may order customized copies. Please contact RCH Educational Resource Centre on +613 9345 547

1. RCH transition policy

Transition is a process not an event. Transfer to adult health care is an event.

As stated in the RCH Access Policy:

New patients aged 18 years or over will not be admitted to RCH. Exemptions include any adults donating organs, post natal mothers and cleft palate patients.
Patients aged 17 years of age should not be placed on the waiting list for any procedure if this is unlikely to occur within 6 months, or it is likely that they will be of adult age (18 years +), then a transfer to an adult hospital and waiting list is required.
The process of Transition should begin in early adolescence at 12-14 years of age. The Transfer is the event where young people move to an adult facility between 18-19 years of age.
It is important to prepare adolescents, including consideration of timing of their transfer.ﾠAvoid transfer during the final year of school, either transferring before final school year or waiting until studies are completed.
The patient is not considered transferred until the first appointment at the adult hospital. Any visit, including emergency prior to that should take place at the RCH.
Guidelines for inpatient wards preparing for Transition and Transfer to an adult health care provider are attached Ward staff guidelines for transition (PDF)

Exemptions for treatment and transition:

In some circumstances it is in the patient's best interest for treatment to be extended past the usual transition age. Please discuss such exemption with the Chief of Surgery or Chief of Medicine.
All patients at the age of 17 years should have a Transition plan in place and require anﾠexemption approved for ongoing treatment at RCH. This applied to ALL treatment, including inpatient admissions, surgery, day medical treatment, and outpatient follow up.ﾠPatients requiring ongoing treatment are required to have aﾠMedical and Surgical Treatment Exemption form (trial) completedﾠﾠand sent to either the Chief of Surgery or Chief of Medicine for approval. During the trial of this form (July- September 2008) please also complete the attachedﾠEvaluation of Treatment Exemption formﾠ for feedback.
Cleft lip and palate patients have been granted a permanent exemption and do not need to have this form completed. These patients are to complete their plastics and dental work at the RCH before discharge to adult care.
Palliative patients might or might not be exempt from transition. Decision is made by the treating team on an individual basis.
See attached theﾠTreatment Exemption process chart for treatment of patients above the age of 17 years.ﾠ

The fundamental principles inﾠtreatment of patients 17 years + are:

Patients 17 years + who have a first presentation or referral to RCH should be transferred onto an adult health care facility. If unable to do this, an exemption for overage treatment at RCH must be sought and granted before any treatment can be provided.
Patients 17 years and older who are current patients of RCH and require ongoing treatment, require a form to be completed and approval granted.
Patients 17 years and older requiring a booking for surgery or treatment (either day surgery or inpatient) will require this form to be approved before a booking can be made|
Once an approval for overage exemption is granted, it is valid for 12 months. This allows time for transition plans to be developed and transfer to adult care to occur.
If there are reasons why a patient requires an exemption fro longer than 12 months, a further request will need to be made
Once the Chief of Medicine/ Surgery approves a request for treatment exemption for an overage patient, a Clinical Alert will be placed on IBA and the approved form will be returned to requesting doctor to be attached to admission paperwork, booking requests or filed appropriately in the patients medical record.
After approval, transition and transfer to adult care must be discussed and reviewed with the patient and family on an ongoing basis.

RCH departmental policy:

It is advisable for every RCH Department to have their own Transition Policy relevant to their patient diagnostic group incorporating their special needs into this policy and identifying individual departmental processes and responsibilities.
You can create your own Departmental Transition Policy using this template Transition policy for RCH departments

2. Why do we need to transfer young people at all?

Ultimately, the goal is to achieve the best outcomes possible for our patients and their families in areas of health, independence and adulthood. Research confirms that a planned transition is vital for the healthy psychological development for young people. As health professionals, it is our role to assist adolescents under our care to become, where possible, happy, healthy, competent adults who can manage their condition as best as they can.

Here are some links to journal articles that further confirm the above.

3. Preparing patient's for the adult health care system and their own self management

The literature available on Transition to adult care, indicates that participation and empowerment are key principles in the transition process, allowing the young person more opportunity to have a positive and effective transfer experience, therefore reducing the likelihood that young people will drop out of the health care system. Young people need to be provided with information and support to develop skills to manage their own health care and adequately prepare during the transition process for the transfer to adult care.

Information available for young people includes the Transition Information Kit (TIK) and the MyHealth Passports resource.

Transition Information Kits (TIKs):

Transition Information Kits can be made up and given to young people.ﾠThe TIK isﾠdesigned to provide general transition information to any patient over 15 years of age to prompt thinking and discussion about transition. TIKs are distributed via outpatient clinic staff but may be put together by individual departments as needed and customized to the department's needs.

To make a TIK, obtain the RCH presentation folder and print the documents below. Put the printouts in the folder. You can also put the patient's name on the folder to make it more personal or add any useful information specific to your department. See a Transition information folder (PDF) as an example.

Presentation folders are available via Material Resources (stock number 948943).
Transition Information 'stickers' are available through RCH Educational Resource Centre - Order Number: ERC 070812

Basic contents of the TransitionﾠInformation Kitsﾠ(TIKs)ﾠare:

The Health Care Skills Checklist is a toolﾠto assist young people to develop skills they will need for managing their own health care once they transfer to the adult system. It is expected that this document will be shared between parents, young peopleﾠand health care professionals to review the skills the young person is developing. It will assist in determining when/if the young person is ready to negotiate the adult world.

MyHealth Passports:

MyHealth Passport is a resource developed by The Hospital for Sick Children (Sick Kids) in Toronto, Canada and is a wallet sized passport of health information for young people to use in an emergency or during appointments with health professionals where they can show the information and not have to constantly repeat their story. This resourceﾠallows young people to learn about their health care, and be more independent and responsible for their health care. It provides information about the young person's medical condition, medications,ﾠmedical contact numbers and other relevant information.

It is advisable that the MyHealth Passport is created and developed with both theﾠyoung person and their health care professional to ensure accuracy of information and allows the opportunityﾠforﾠyoung peopleﾠto ask questions about their health and health care history. There is no set age limit for the creation of this passport however to assist health professionals, some Guidelines for use of MyHealth passport have been developed. Click here to downloadﾠGuidelines for use of MyHealth Passports.ﾠIt is advisable that the young person sits in front of the computer and types the information in themselves to ensure ownership and an understanding of their health issues.

This resource does not replace the need for health professionals to provide the young person, their family and the adult health care provider with aﾠsummary of their health care for theﾠtransfer to adult care. All patients transferred to adult care require a summary of their health care to be completed.

To create a passport with a young person, simply click on the linkﾠMyHealth Passportﾠand select the relevant template to use for your patient's medical condition.

Other ways to prepare young people for adult health care:

Please print out any other sections of this website that would be of use to your patient/family and include brochures/documents relevant to your patient group including any information of adult clinics your department refers patients to.

For further information on courses for clinicians in working with adolescents, providing information on promoting self management in young people, or managing adolescents please contact the Centre for Adolescent Health on 9345 5890.

4. Principles of transition

Initiate discussion regarding transition in early/mid adolescence as an integral part of the overall health care plan thus making it a normal part of caring for an adolescent with a chronic illness.
Transition is most successful where there is a designated professional who, together with the young person and family, takes responsibility for the process and a team approach with all the multidisciplinary team involved.
Young people and their families inclusion in the development of the individual transition plan is vital to the success of the process.
Young people and/or their families will experience changes with the move to the adult system and young people need to develop new skills during the transition process. Families and carers are often anxious in the changes in their role from from primary carer to support provider.Supporting young people and their families through this process is extremely important.
Prepare families for a different system as adult hospitals do run differently. Providing specific information about ongoing care availableﾠandﾠby whom is essential. If services are not clearly obvious, discussion with the family about options available and differences in the adult system need to take place.
Encourage families and patients to be assertive and if necessary to be a strong advocate for their son/daughter.
The process of transition to adult health care needs to occur within a developmental context of when the young person is ready for this transfer and during the most appropriate time, such as avoiding the final year of school or during unsettled times in their illness.
Health Professionals and Carers need to recognize the importance of promoting the young persons increasing capacity for self care (in conjunction with their ability) to prepare them for adult health care services.
Communicate and collaborate with your adult hospital counterparts and develop clear processes to ensure successful transfer to adult services for RCH patients
See the checklist Ten golden rules of transition (Word) to guide you in ensuring you meet all the requirements of a successful Transition.

5. How do I transition and transfer my patients to adult health care?

Process of transition and transfer in 8 easy steps

Download a Word Version of these steps for your own useﾠEasy steps to transfer RCH patients to adult care

Steps	Action
Step 1	DISCUSS TRANSITION AND IDENTIFY APPROPRIATE OPTIONS FOR TRANSFER FACILITY Discuss transfer with patient and family and identify receiving adult hospital/specialist(s) in consultation with patient. SeeﾠAdult clinics available in adult health servicesﾠon this webpage to determine options available or utilize your department's collegial networks for transfer of patients. Giveﾠpatient the Transition Information Kit (TIK) and the Health care skills checklist (Word) and begin the process of supporting your patient to develop independent and self management skills, and parents in allowing this to occur. NB When deciding to transfer a patient keep in mind the three principles of successful transition: Compassion, Communication and Common Sense and refer to the checklist in theﾠTen golden rules of transition (Word)
Step 2	DETERMINE WHO IS INVOLVED WITH PATIENT AND INFORM ALL RCH DEPARTMENTS OF PLAN TO TRANSFER For patients with complex needs who have more than one RCH Department involved, an Intra hospital transfer letter (Word) can help with communicating between departments in RCH for a co-ordinated transfer. This letter is a guide and can be modified to suit your departments needs. Once you have clarified the intention and treatment plan for all Departments involved, you can proceed with the transition process and transfer to adult care. For patients with relatively simple needs and have no other RCH Departments involved, a referral letter or Simple discharge letter (Word) can be utilized.
Step 3	START COLLECTING RELEVANT INFORMATION FOR TRANSFER Commence Transfer Summary Record (TSR) (Word) When complete, this document will provide the adult team with a health summary involving *all* disciplines involved in the patients care and outlines any current issues. A copy of this document will be given to the patient. Insert patient name, UR and other demographic details in TSR and save to new document etc. Identify other RCH Dept. involved in patient's care (include Allied Health), using CLARA, IBAﾠor Medical Record to guide you. Insert each Department or Professionals name, contact details and telephone number, down left hand column of TSR. Complete your section of TSR and organize to e-mail/ send the TSR to relevant Doctors.(NB: You will need to explain the purpose of the TSR until this becomes familiar to all staff). You will need to arrange to have this information returned to you or an administration staff member to allow for this to be compiled before the document is used in the transfer to adult health care. Your patient and family need to be reassured that whilst the transition process is slow, and can take some time to co-ordinate and they can continue to attend RCH until they are linked into an adult service.
Step 4	FINAILISE YOUR REFERRAL INFORMATION Complete short referral letter to accompany Transfer Summary Record. Ensure the patient and family have been involved in discussions of where you are referring to.ﾠIf required, assist in arranging a visit to the adult facility before their first appointment to alleviate any fears, concerns or anxieties.
Step 5	SEND THE REFERRAL TO THE IDENTIFIED ADULT HEALTH CARE FACILITY AND OTHER RELEVANT PEOPLE Collate information on Transfer Summary Record (TSR) (follow up any outstanding information) Send referral letter and TSR to adult hospital specialists. A copy of the TSR must also be given to the patient and their family, Local GP, Medical Records, RCH Transition Co-ordinator and any other relevant personnel such as other RCH Departments, and external services involved with the patient.
Step 6	ENSURE THE PATIENT HAS SECURED AN APPOINTMENT AND HAS BEEN ADEQUATELY LINKED IN TO ADULT SERVICE Ensure an outpatient appointment has been made at the adult hospital after your referral, ideally within 3 months. Reassure patient that in case of emergency they can continue to attend RCH. *Transfer to the adult hospital is not complete until the patient has their first appointment.*
Step 7	FOLLOW UP PATIENT AFTER THEY HAVE VISITED THE ADULT FACILITY You may have a final appointment after the patient has had their first appointment at the adult health care service. This will depend on the individual circumstances of each patient. At this appointment it may be worthwhile to provide the patient with a Transition graduation certificate (Word) If you don't have a final appointment, you may follow up the patientﾠby phone, letter etc. To monitor our effectiveness, we ask young people to complete a brief Pre and Post Transition Survey which you could send to them Patient pre transition questionnaire (Word) Patient post transition questionnaire (Word)
Step 8	RECORD YOUR PATIENT'S TRANSFER ON IBA FOR DATA COLLATION & SHARED KNOWLEDGE OF THE TRANSFER To enable RCH to determine how many patients have been successfully transferred to adult care, and for all RCH Departments to be aware of where patients have been referred to an IBA Alert is required. To Add an ALERT on IBA : Find the patient on IBA. Go to 'Information menu' or for some users it will be the 'Functions menu'- scroll down and click on 'Alerts' Go to 'Add Alert' menu (top right corner) - scroll down and click on 'Notify Care Manager'. The 'Add Alert' box will appear. In the box - find 'Alert menu' - scroll down and click on 'Transition Patient' Complete the rest of the Blue Fields only which are mandatory. For the date of Transfer click on the 'clock' icon it will auto appear to the current date. If the Patient was transferred on a different date, click on calendar next to clock to select the appropriate date. Skip the next three fields (white fields) and proceed to 'Reaction Comment'. Type 'Patient care transferred to........' and any other brief comment you believe is relevant (e.g. name of adult receiving doctor if applicable) Click 'Add' A black triangle with an exclamation mark in the middle will appear next to the patient's name To modify the alert, click on the triangle next to patient's name, click on it again once 'Alerts' screen appears and make required changes. Click 'Update'

6. Accelerated Care In Emergency (ACE) patients and transition/ transfer to adult health care

For any patients who are part of this program (also known as 'frequent flyers' in the RCH emergency department) the ACE staff will be happy to provide a one page laminated document that outlines suggestions for care when these patients present to adult emergency departments

This Emergency proforma (Word) is a useful tool to assist staff that may not be familiar with the patient. It is also reassuring for the patient to carry this with them so they are not required to explain their often detailed history repeatedly. However, it must be understood that this will serve only as a guide. It does not replace the considerable knowledge and expertise of the staff in adult health care settings.

7. Adult clinics available in adult health services

There are clinics in many adult hospitals. Some are specificallyﾠfor young adults with complex disabilities and there are also other transition clinics for variousﾠmedical conditions. See the tables below for your information.

Young Adults with Complex Disabilities Clinics

Hospital	Condition	Contact	Mailing Address
Monash Medical Centre Young Adults with Complex Disabilities Clinic medical referral required	Spina Bifida Cerebral Palsy Other conditions	Liz MacKenzie Tel: 03 9594 2290 (Social Work Dept)	Social Work Department Monash Medical Centre Locked bag 29 Clayton South, Vic 3169
St. Vincent's Hospital Young Adults with Complex Disabilities Clinic self referral	Cerebral Palsy	Karen Phipps Tel: 03 9288 4672 (Tues, Wed, Fri)	Bolte Wing St. Vincent's Health PO Box 2900 Fitzroy, Vic 3065
Royal Melbourne Hospital (Royal Park) Young Adult Disability Clinic self referral	Spina Bifida	Carlee Holmes Tel: 03 8387 2000 (Mon, Tues, Wed)	Physiotherapy Department Royal Melbourne Hospital Royal Park Campus PO Box 7000 Carlton South 3053
Ann Caudle Centre Campus (Bendigo) Young Adults with Complex Needs Service medical referral required	Spina Bifida Cerebral Palsy Other conditions	Cheryl Ludwik Tel: 03 5454 6454 Reception: 03 5454 8500	Outpatient Rehabilitation Services PO Box 126 Bendigo, Vic 3552

Other Transition Clinics

Clinic/Location	Staff	Contact	Address
Urology Monash Medical Centre - Special Medicine Centre Transition Clinic referral from paediatric doctor or GP	Paediatric Urologist Adult Urologist Clinic held at Clayton campus	Ph: 03 9594 7788 Fax: 03 9594 6925 Referrals to be faxed to Katherine Lombadi. Fax referral/ summary before an appointment can be made. Specify that referral for Transition Clinic	Urology Transition Clinic 246 Clayton Road Clayton, Vic 3168
Immunology Alfred Hospital and Royal Melbourne Hospital About the adult clinic at the Alfred (PDF)	Immunology Registrar	Alfred Hospital Ph: 9276 2934 Fax: 9276 2245 RMH Priority phone number for GPs only: 9349 2280 Fax: 9342 4234	Private Consulting Suites Ground floor, Alfred Hospital, Commercial Road, Prahran Outpatient Appointment Desk, The Royal Melbourne Hospital, 3050
Dermatology Royal Melbourne Hospital (Epidermolysis Bullosa patients also seen)	Dermatology Registrar	RMH Priority phone number for GPs only: Ph: 03 9349 2280 Fax: 03 9342 4234	Outpatient Appointment Desk The Royal Melbourne Hospital, 3050
Inflammatory Bowel Disease Clinic St Vincent's Hospital,Melbourne	Gastroenterology Registrar IBD clinics held on Monday Mornings	Ph: 9288 3475 Fax: 9288 3489 make sure Inflammatory Bowel Disease clinic* is specified when booking*	Ground Floor, Daly Wing, St Vincent's Hospital, Melbourne Fitzroy. Vic
Cardiology Services Royal Melbourne Hospital About the adult clinic at Royal Melbourne Hospital (PDF)	Cardiologist	Enquiries: 9342 7575 Appointments: 9342 8899	1South 1st floor, Royal Melbourne Hospital, Main Building, Grattan St, Parkville. VIC. 3050
Cardiology Grown-Up Congenital Heart Disease Clinic Monash Medical Centre About the adult clinic at Monash Medical Centre (PDF)	Cardiologist 1st Wed of every month	Ph: 9594 4175 Fax: 9594 6061 Please fax referral first before an appt can be made	Special Medicine Centre Monash Medical Centre (behind McCulloch House) Clayton Campus 246 Clayton Rd, Clayton Vic 3168
Respiratory Cystic Fibrosis Clinicsﾠ	Respiratory doctors Clinical Nurse Coordinator	Alfred Hospital CF Coordinator- Felicity Finlayson Ph: 9076 3443 Monash Medical Centre CF Coordinator- Rachael McAleer Ph: 9594 2915
Plastics Royal Melbourne Hospital Department of Plastic and Reconstructive Surgery Transition Clinic	Dr. Alan Breidahl Craniofacial Clinic	Ph: 03 9342 7410 Fax: 03 9342 8441 All referrals to Karen Marchese. Appointment sent to Patient after referral received	Level 7, Plastic Surgery Office Royal Melbourne Hospital Grattan Street, Parkville. VIC. 3050.
Endocrinology Austin Health Mens Health Clinic Medical referral required	Dr Matthis Grossmann Dr Kate Bate (Endocrinologists)	Ph: 94962710 Ph: 94962975ﾠ Fax 94962695	Attention to relevant Medical Specialist Mens Health Clinic, Endocrine Centre for Excellence, Austin Health, Heidelberg 3084
Endocrinology Austin Health Womens Clinic- disorders of Sexual Development. (Mixed Endocrine/ Gynaecology conditions)	Dr Matthis Grossmann Dr Kate Bate (Endocrinologists)ﾠ Assoc ProfﾠSonia Groverﾠ(Gynaecologist)	Ph: 94962710 Ph: 94962975ﾠ Fax 94962695	Attention to relevant Medical Specialist Womens Clinic Endocrine Centreﾠof Excellence, Austin Health,ﾠ Heidelberg 3084
Endocrinology Turners Long Term Clinic	ﾠDr. Beverley Vollenhoven (Gyneacologist)	Ph: 9594 2372 Ph: 9594 2373 A referral is required from your local doctor or specialist.	Turners Long Term Care Clinic. ﾠClinic D, Monash Medical Centre, 246 Clayton Road, Clayton.ﾠ

8. All useful transition and transfer documents

Below is the complete set or resources you can utilize in the Transition Process and in the final Transfer to an adult health care facility. These documents have been designed to provide a co-ordinated process for your patients and also to assist health professionals in managing this complex task.

Transition policy for RCH departments
Overage exemption form (Word)
Overage process chart (PDF)
Ward staff guidelines for transition (PDF)
Transition Information folder (view of the folder- contents included are the two documents below)
Information for young people (PDF)
Health care skills checklist (Word)
Ten golden rules of transition (Word)
Easy steps to transfer RCH patients to adult care
Intra hospital transfer letter (Word)
Simple discharge letter (Word)
Transfer Summary Record (TSR)
Transition graduation certificate (Word)
Patient pre transition questionnaire (Word)
Patient post transition questionnaire (Word)

Last Updated 02-Sep-2008. Authorised by: Felicity Sloman. Enquiries: Felicity Sloman.