Santos Sara, Orkin Julia, Abells Dara, Allemang Brooke, Arenas Rodriguez Bianca, Colapinto Kimberly, Constas Nora, Heath Mackenzie, Henze Megan, John Tomisin, Lippett Robyn, Miranda Susan, Soscia Joanna, Teicher Jessica, Thomson Donna, Tyrrell Jennifer, Vandepoele Eryn, Wentzel Karla, Yates Darryl, Cohen Eyal, Toulany Alène
SickKids Research Institute, Child Health Evaluative Sciences, Toronto, ON M5G 0A4, Canada.
Complex Care Program, Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.
Children (Basel). 2025 Aug 8;12(8):1043. doi: 10.3390/children12081043.
: Transitioning from pediatric to adult services can be challenging for youth with complex chronic health conditions, especially those with multi-morbidity. These youth often require extra coordination and support during this phase of their healthcare journey. Building upon existing provincial and national initiatives for transitions from pediatric to adult healthcare services, we have developed a hospital-wide program within one of Canada's largest children's hospitals that incorporates an integrated care model aimed at better serving these patients and improving outcomes. : Guided by provincial quality standards, an environmental scan and knowledge user engagement were conducted to develop the program, followed by an implementation phase, where the model was piloted. Ongoing learnings from the pilot continue to inform program implementation and evaluation. : The Transition to Adult Care (TAC) program offers disease-agnostic care to youth with complex needs for 1-3 years, including 1-year post-transfer, addressing the fragmentation of care across multiple services, organizations and providers. Our interdisciplinary team works in partnership with youth and caregivers to deliver transition navigation, easing the burden on patients and families by tailoring transition supports to each individual youth and caregiver. Preliminary data from the pilot revealed a lack of awareness about transition resources and timelines; however, with early engagement and flexible support beyond age 18, youth were able to complete their transition successfully. The TAC program demonstrates a systems-level approach to improving transition to adult care for youth with complex health needs by integrating individualized support, cross-sectoral collaboration, and continuous quality improvement. Early engagement, flexible post-transfer support, and close partnership with youth, caregivers, and providers are key to facilitating transition. These learnings can inform broader implementation efforts and help address persistent gaps in transitional care across healthcare systems.
对于患有复杂慢性健康状况的青少年，尤其是那些患有多种疾病的青少年来说，从儿科服务过渡到成人服务可能具有挑战性。在他们的医疗保健过程的这个阶段，这些青少年通常需要额外的协调和支持。在现有的省级和国家级从儿科到成人医疗服务过渡倡议的基础上，我们在加拿大最大的儿童医院之一内制定了一项全院范围的计划，该计划采用了一种综合护理模式，旨在更好地为这些患者服务并改善治疗效果。
在省级质量标准的指导下，进行了环境扫描和知识用户参与以制定该计划，随后进入实施阶段，在该阶段对该模式进行了试点。试点过程中的持续经验教训继续为计划的实施和评估提供信息。
成人护理过渡（TAC）计划为有复杂需求的青少年提供为期1至3年的疾病无关护理，包括转移后1年，解决了多个服务、组织和提供者之间护理分散问题。我们的跨学科团队与青少年及其照顾者合作，提供过渡导航服务，通过为每个青少年和照顾者量身定制过渡支持，减轻患者和家庭的负担。试点的初步数据显示，对过渡资源和时间线缺乏认识；然而，通过18岁以后的早期参与和灵活支持，青少年能够成功完成过渡。TAC计划展示了一种系统层面的方法，可以通过整合个性化支持、跨部门合作和持续质量改进，改善有复杂健康需求的青少年向成人护理的过渡。早期参与、灵活的转移后支持以及与青少年、照顾者和提供者的密切合作是促进过渡的关键。这些经验教训可为更广泛的实施工作提供参考，并有助于解决医疗系统中过渡护理方面持续存在的差距。
