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Transition/Transfer of Patients to Adult Care
Transition Project Background

Most children with pediatric chronic health conditions (98%) now survive to adulthood.

This 1st generation of youth and young adults (a unique population), is not routinely accounted for in the adult health care system, but requires long-term specialty care. They are vulnerable due to the complexity and rarity of their conditions, the lack of skilled adult providers, and face challenges adjusting to the culture of adult individualistic care after a lifetime of family centered pediatric care.  The BC Pediatric Society is concerned about this issue.

Transition Supports for Community Pediatricians (January – October 2016)

The Specialists Services Committee (SSC) has funded a BC Pediatric Society project to help Community Pediatricians address challenges encountered when transitioning youth with chronic health conditions to adult systems of care (i.e. to Family Practitioners, Adult Specialists and/or allied health supports). Drs. Aven Poynter and Todd Sorokan are project Co-Leads.

Project activities were guided by an environmental scan conducted in 9 BC locations (winter 2015-16)  followed by consultations with members of Advisory and Steering Committees and other key stakeholders. Scan interviews explored 3 key areas: current transfer practices, transfer of medical records and other transition supports needed. Not surprisingly the three big challenges identified by Community Pediatricians participating in the scan were: 

  • Finding adult service providers (especially family physicians) and allied health supports
  • Accessing mental health services and supports for youth moving to the adult healthcare system
  • Finding community resources to help families involved in a transition process 

Some challenges are within the project scope and some are systemic.  Based on information from this scan, other information sources, and existing resources such as the ONTRAC initiative, the BCPS project developed a set of resources that were vetted by project committee members and physicians participating in October 2016 Consultation sessions in Prince George, Penticton, Vancouver, Surrey and Nanaimo. Small sessions were also held with community pediatricians in Terrace and Prince Rupert. 

Draft resources were reviewed by a total of 40 community pediatricians, family practitioners and adult specialists:

  • BCPS Medical Transfer Summary Form (MTS)
  • Information for Pediatricians Transitioning Patients without a Family Physician
  • Information for Pediatricians Trying to Locate an Adult Specialist for a Transitioning Patient
  • List of Organizations and Programs Supporting Transitions
  • Information for Transitioning Patients with a Mental Illness
  • Compensation for Community Pediatricians Transferring Patients (Fee for Service)
  • Case studies that illustrate use of the tools

Overall, Consultation participants were pleased with the resources and considered them useful in facilitating the transfer process.

Next Steps (January – April 2017)

Following incorporation of minor changes to the resources as suggested by Consultation participants, the resources have been updated in preparation for a pilot in early 2017. Approximately 25 physicians who have expressed interest in being involved in the pilot will use or otherwise review the resources in their practices. Debrief interviews will explore utility, relevance and ease of use of the resources – in particular, the MTS Form.

Additional Information

Newsletter #1 June 2016:
Transition Supports for Community Pediatricians

Newsletter #2 August 2016:
Transitioning Patients from Community Pediatricians into Adult Care Project: Overview

Newsletter #3 December 2016:
Transitioning Patients from Community Pediatricians into Adult Care Project: BCPS Medical Transfer Form

Newsletter #4 March 2017:
BCPS Transitions/Transfer Project: 2 New Resources

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© 2016 BC Pediatric Society