GuidebookSix Core ElementsElement 2 Transition Tracking and MonitoringElement 2.1

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
Transition process

When preparing youth to transition out of child and adolescent mental health services, there are several factors that need to be considered. For many organizations, this transition is age-dependent. For example, some organizations require young adults to transition to adult mental health services when they turn 18. Other organizations may specify additional criteria for transitions, such as completing a set number of sessions before transitioning and/or receiving a specific psychiatric diagnosis (e.g., psychosis).

Where possible, the transition identification process should begin at least six months prior to the planned transition. A transition plan should be established during the initiation of the transition process (see Component 3.3 for information on developing a transition plan). When applicable, the transition navigator, primary care provider, family/caregiver, youth, and all other significant care providers should be included.

NOTES FROM A NAVIGATOR

My role as a navigator is to connect with families and individuals, patients, who are aging out of [site A], so who are in that transition period…I connect with the family, connect with the youth, to support them in terms of making sure that they're prepared, or they have the tools that they need to have a successful transition when they leave. 

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Uncomplicated access, seamless transitions, continuous care.

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Copyright Dr. Kristin Cleverley 2023.