CAPHC Guideline for Transition From Paediatric to Adult Health Care for Youth with Special Health Care Needs

The CAPHC Transitions Community of Practice is proud to announce the release of the CAPHC Guideline for Transition From Paediatric to Adult Health Care for Youth with Special Health Care Needs:  A National Approach.

The Guideline and the 19 personal, clinical, and system – level recommendations are based in the evidence and built on the knowledge, experience and consensus of a large and engaged national network.

We would like to recognize the leadership  of the Transition CoP Co-chairs, Mary Paone, Nursing Lead for Transition, ON TRAC Transition Initiative, BC Children's Hospital and Dr. Khush Amaria Clinical/Health Psychologist and Team Lead, Good 2 Go Transition Program, The Hospital for Sick Children as well as the Guideline Development Group  who committed to this work in 2012 and have worked countless hours to complete this Guideline on behalf of the CAPHC Transitions Community of Practice.

This Guideline was developed to address the CoP’s definition of transition as a purposeful, planned movement of adolescents with chronic medical conditions from child-centered to adult-oriented health care that is supported by individualized planning in the paediatric and community settings, and results in a coordinated transfer of care and secure attachment to adult services. As such, the objective of the Guideline is to support a successful transition framework from paediatric to adult care that results in individuals who are better equipped to navigate the system and better able to manage their own health.

These five key questions influenced the development of subsequent recommendations:

  1.  What are the key components necessary for a successful transition/transfer?
  2. How can clinicians support families and youth through the transition process?
  3. How can the system support clinicians in providing a successful transition process?
  4. How do we know when a clinical group or system has adopted and integrated transition/transfer processes?
  5. How do we evaluate and monitor a successful transition?

Guideline Aims

  1. To influence transitioning at the person- and clinical-level, prompting change over time to the system level;
  2. To provide a framework for a supportive process for transitioning from paediatric to adult health services; and 
  3. To identify collaborative processes, tools and resources for all stakeholders in the transition of youth to adult healthcare.

To learn more about the Transition CoP and the Guideline please click this link:

A Guideline for Transition from Paediatric to Adult Care