Transition Policies and Guidelines

Last modified by Lisa Stromquist on 2018/05/25 21:26

This is a collection of policy/position statements, reports and guidelines gathered from Canada, the United States and England. This list does represent an endorsement form the CAPHC Transition Community of Practice and are for illustrative purposes.  If you would like to add other resources please contact

Policy/Protocol/Position Paper

Alberta Children & Youth Initiative
Transition planning protocol for youth with disabilities: Your guide to reaching new heights. 
The Transition Planning Protocol for youth with Disabilities recognizes the importance of addressing the process of transition for youth with disabilities. The protocol specifies the transition planning process, the components of a transition plan and the shared commitment of Alberta government ministries and their partners to youth with disabilities and their families during the critical period of transition to adulthood.
For more information ... 
British Columbia Ministries/ Government
Cross Ministry Transitional Planning Protocol for Youth with Special Needs           
The Cross Ministry Transitional Planning Protocol for Youth with Special Needs was developed in 2009 through the collaboration of nine government ministries to outline transition requirements for youth as they age out of pediatric programs.  
For more information ... 
Canadian Pediatric Position Statement (2007/2016) Adolescent Health Committee
Position Statement:Transition to Adult Care for Youth with Special Health Care Needs   
The Canadian Paediatric Society Position Statement for transition to adult care was developed first in 2007 and reaffirmed in 2016. The Canadian Paediatric Society supports the provision of developmentally appropriate care for youth with special health care needs as they move into the adult-oriented health care system. The present statement provides the background, framework and tools for paediatricians, family physicians, other health care professionals, parents and youth to ensure a successful transfer of care and transition to adult life.
For more information ... 


BC Children's Hospital
ON TRAC Transition Clinical Practice Guideline 

The Transition Clinical Practice Guideline was  developed to facilitate the comprehensive planning, preparation and transfer of youth with CHC/Ds to adult care services, ensuring youth engagement and attachment to primary care and adult services. The evidence-based and -informed recommendations outline timing, documentation, roles, education and resources for the transition of youth. These recommendations also provide direction for accreditation.
For more information...
Debra Stewart, Matt Freeman, Mary Law, Helen Healy, Jan Burke-Gaffney, Mary Forhan, Nancy Young, & Susan Guenther, 2009; Published and distributed by CanChild Centre for Childhood Disability Research 
The Best Journey to Adult Life for Youth with Disabilities: An Evidence-based Model and Best Practice Guidelines for the Transition to adulthood for Youth with Disabilites Ontario  
The Guidelines are organized into six main themes that emerged from comprehensive literature reviews, consensus meetings and focus groups with key stakeholders.Transition to Adulthood for Youth with Disabilities. Ontario
For more information...
Nova Scotia Health Authority 
Guidelines for Transition of Youth to Adult Mental Health and Addiction Services within Nova Scotia Health Authority
This document is intended as a guide to support a planned and coordinated transfer of an individual receiving mental health and addiction care from the IWK to NS Health Authority Central Zone. The guideline outlines the philosophical approach to support successful transitions and identifies the key roles of youth and family, primary care physician, IWK and NSHA Adult Service providers and treatment settings.
For more information...
The Hospital for Sick Children
Guidelines for transition from pediatric to adult health care - transplant program 
The Hospital for Sick Children Good 2 Go partnered with the Transplant & Regenerative Medicine Centre at SickKids to develop Transition of Care Guidelines and has supported programs in developing various stages of pathways.
For more information...
American Heart Association
Best Practices in Managing Transition to Adulthood for Adolescents With Congenital Heart Disease: The Transition Process and Medical and Psychosocial Issues
Sable, C., Foster, E., Uzark, K, Bjornsen, K, Canobbio, M. et al (2011).  Best practice in managing transition to adulthood for adolescents with congenital heart disease: The transition process and medical and psychosocial issues: A scientific statement from the American heart association, circulation, 123, 1454-1485.

A guideline for the transition of youth with Congenital Heart Disease (CHD)  - an American Heart Association Scientific Statement.
The goals of a formal transition program are to prepare young adults for transfer of care. It should provide uninterrupted health care that is patient centered, age and developmentally appropriate, flexible, and comprehensive. It should include age-appropriate education about medical conditions and promote skills in communication, decision making, self-care, and self-advocacy.

For more information...
Center for Health Care Transition Washington DC
Got Transition Six Core Elements of Health Care Transition   
The Six Core Elements of Health Care Transition 2.0 define the basic components of health care transition support and the corresponding sample tools provide tested means for transitioning youth to adult health care providers. These transition resources are consistent with the AAP/AAFP/ACP Clinical Report on Transition. Got Transition/Center for Health Care Transition Improvement is a cooperative agreement between the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health. Our aim is to improve transition from pediatric to adult health care through the use of new and innovative strategies for health professionals and youth and families.
For more information...               


Care Quality Commission England
From the Pond into the Sea - Children's transition to adult health services June 2014
“This report describes a health and social care system that is not working, that is letting down many desperately ill youngsters at a critical time in their lives. We have put the interests of a system that is no longer fit for purpose above the interests of the people it is supposed to serve.”
Professor Steve Field, Chief Inspector of Primary Medical Services and Integrated Care
Read the Report...


Springer International Publishing just released a new textbook in May 2018 titled Health Care Transition – Building a Program for Adolescents and Young Adults with Chronic Illness and Disability. It provides the framework, tools and case-based examples needed to develop and evaluate a health care transition planning program that can be implemented regardless of a patient’s disease or disability. Edited by Al Hergenroeder, MD and Connie Wiemann, PhD, the book contains 37 chapters written by more than 75 authors from more than 100 medical centers in North America and Europe.

The book has been published in these formats:
  • Print and e-book versions for purchase by individuals and institutions.
  • Online, as part of the Springer online subscription product,, which is used by institutions.  (If your institution subscribes to SpringerLink, you can access this electronic version of your book at All of our academic library customers worldwide will have the opportunity to select the book for stocking on their shelves and/or to make it available electronically to their patrons via SpringerLink.  

 The book links are and , respectively.

Created by Lisa Stromquist on 2017/04/03 23:20