3.3 Develop individualized transition plan in collaboration with youth (and their family members/caregivers, if appropriate) a minimum of 6-months before planned transition, or as early as possible.
3.3 Develop individualized transition plan in collaboration with youth (and their family members/caregivers, if appropriate) a minimum of 6-months before planned transition, or as early as possible.
The transition plan is a living document that outlines the plan of care throughout the transition process. It should be co-created with youth and their identified care team. This document should outline goals for transition and planned interventions, which will be guided by ongoing transition readiness assessment and youth's priorities for transition care.
This plan should be updated regularly throughout the pre-transition and transition period and should include documented progress of identified tasks. The care team member responsible for each transition task should be clearly identified. The plan should be shared with the current care team and sent to the receiving clinical team along with all other relevant care documentation at the time of transfer.
Resources
To learn more about transition template:
To learn more about service transition plan:
NOTES FROM A NAVIGATOR
As they become adults, and they have to navigate on their own, I do believe that that's where our role really makes a big difference in terms of meeting the youth where they are at, and talking to them and finding out what their needs are…And working collaboratively with them on creating a transition plan and then with the transition plan, we then work strategically to check everything off the list.
