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GMCT
Transition Care
Information for health professionals

Information for health professionals

What is transition and GMCT?
Why we need to concentrate on it?
When should the transition process begin?
Referral to the GMCT Transition Service
Negotiated Agreement - Contracting in transition
Transition Planning Checklist
Guidelines

What is transition and GMCT?

Transition Care refers to the 'purposeful planned movement of adolescents and young adults with chronic physical and medical conditions from a child centred to adult oriented health care system' (Blum et al 1993).

The Transition Care for Young People with a Chronic Childhood Illnesses Group was convened in December 2002. It is one of 22 programs managed by the Greater Metropolitan Clinical Taskforce (GMCT) that reports directly to the Department of Health.

In 2004 a Program Manager and three Transition Coordinators were appointed. The Coordinators are based at Royal Prince Alfred, John Hunter Hospital and Westmead Hospital. The Transition Care Program aims to provide a coordinated approach to improving systems and processes for young people with chronic illnesses/ disability as they move from paediatric health services to adult health services.

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Why we need to concentrate on it?

Research on transition indicates that the current health system generally does not tackle the movement between child and adult care well. Evidence is increasing to show that lack of well planned, effectively coordinated transition processes lead to young people opting out of health services which may then result in poor health outcomes and crisis presentations.

Successful transition means that the young person maintains their health and quality of life and continues to use health care services appropriately.

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When should the transition process begin?

Literature suggests that initiating ongoing discussions about transition should begin when the young person is about 13 years old in order to allow enough time for planning this transition.

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Help With Transition

The program is currently developing a range of generic tools to aid transition:

The Program Manager and Coordinators are also

Meeting with key clinicians to identify service needs
Encouraging young people to have a say in what is needed to improve the current system
Collecting data on current transition programs and service gaps

Referral to the GMCT Transition Service

To refer a young person to the Transition Cordinators, complete this referral form and email or fax to the appropriate Transition Co-ordinator.

For further information contact the Transition Care Program Manager or the Coordinators.

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Negotiated Agreement - Contracting in transition

Contracting, which has its roots in business, has many applications for use in health care. It can be especially useful in the health care of clients with chronic illnesses. Often patients with chronic diseases need to change a number of behaviours to improve their health. It has been suggested that patients with chronic diseases may need encouragement to follow through on behaviour and lifestyle changes and simple patient education and self-care management strategies will not work unless monitored routinely. Negotiated Agreements between the young person, family and health care professionals in the paediatric team offer individualised care and clearly defined goals and expectations

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Who could use a Negotiated Agreement?

This tool can be initiated by any member of the Paediatric Coordinating team or combined transition team, including the young person. For example, it could be used as a tool between:

Clinicians and the young person or vice versa
Clinicians and parents/ carers or vice versa
Clinicians and the young person and parents/ careers or vice versa
Parents and the young person or vice versa

Possible Inclusions in the Negotiated Agreement

Aim of Agreement

A generic statement about the purpose of the contract

Agreement Goals

Specific goals. For example;
Skills acquisition (cooking, dressing, self care etc)
Relationship improvement or development
Improved involvement in the process Responsibly
Each party (person) in the contract will generally have their responsibilities outlined. These could include responsibilities of the team, young person or parent/carer.
It may include responsibilities to abstain from certain behaviours (eg: parents/ carers abstaining from providing assistance that the young person is capable of) or carrying out certain behaviour (eg: young person attending appointments alone).

Outcome

The outcome will largely be for the young person or parent/carer but may on occasion be for a member of the team
The outcome may be a positive or negative consequence, which could include; privileges, bonuses or sanctions.

Monitoring of the agreement

An outline of who, how and when the compliance of the contract will be monitored.
Signed and dated by all parties of the contract (which include the young person, case manager, parents/carer, doctors and therapists)