4.2 Identify everyone else involved in the transition and their specific role in supporting the transition process (e.g. child and adolescent mental health services, adult mental health services, youth and family members/caregivers, transition navigator, primary care practitioners, etc.).
4.2 Identify everyone else involved in the transition and their specific role in supporting the transition process (e.g. child and adolescent mental health services, adult mental health services, youth and family members/caregivers, transition navigator, primary care practitioners, etc.).
Work with youth (and their family/caregiver, if appropriate) to identify the clinicians and other individuals they consider part of their transition care team and support network. This may include specific transition navigators, primary care providers, school-based services, peer support workers, etc. The identification of transition team members will also be informed by your organization's framework or policy for responsibilities related to transition within care teams (see Component 1.5).
When defining roles, consider when each team member will be engaged during the transition process and the capacity in which they will be involved. This is also an opportunity to identify current gaps in care that need to be addressed before the transition
The specific roles and responsibilities of each team member should be captured and regularly updated in the transition plan. For more information, refer to the transition plan document resources in Component 3.3.
NOTES FROM A NAVIGATOR
[This] would be collaborative process, and the transition plan would be created with the young person, with their families and with the Multi-Disciplinary team, so we all know what to expect upon discharge.