4.1 Identify the most responsible person to coordinate the transition process, act as the main contact, and ensure continuity in the youth’s care.

A designated “most responsible person” should serve as the primary contact person throughout the transition. They are responsible for ensuring continuity of care, and acting as the coordinator of the care transition. This person may or may not be the same individual as the traditional “most responsible provider,” who is the physician or other registered health provider responsible for overseeing the treatment and care of the patient or client. This person may be the youth's child and adolescent mental health services clinician or the organization's transition navigator.

A transition navigator is a registered health professional who has expertise in transition coordination and case management, and who provides short term support (often 1-6 months) during the transition period (Cleverley et al., 2018). They work with youth (and family/caregivers, if appropriate) and members of the clinical team to identify needs post-discharge and goals for transfer of care. They have a strong understanding of community programs and resources and are able to work with youth to identify and connect with appropriate services. They continue to provide support to the youth post-discharge and throughout the referral and transition to adult services or other appropriate services. They may also provide psychoeducation and some short-term therapeutic support while the youth is between services.

Resources

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For more information about the transition navigator role, and examples of its implementation:

Facilitating Effective Transitions from Hospital to Community for Children and Adolescent Mental Health Services: Overview of the Transition Support Worker Role and Function

The Sunnybrook Family Navigation Project

Michael Garron Transitional Youth Program