Transition readiness and transfer from paediatric to adult health services — formative SAQs

SAQ 1 (10 marks)

A 17-year-old with type 1 diabetes has been managed solely in paediatric services. No transition plan exists and no adult provider has been identified. Outline a structured transition plan to adult care. ^{[1] [12]}

1. Define health-care transition versus simple transfer. (2) ^[1]
2. List the staged components of a structured transition pathway. (4) ^{[1] [4]}
3. Describe the transfer package that must travel with the young person. (4) ^[1]

Model answer

Transition versus transfer. Transition is the purposeful, planned, multi-year process of preparing, moving and integrating a young person from child-centred to adult-oriented care with continuous services. Transfer is only the single administrative handoff event inside that process. Treating transfer as the whole process is the central error that produces loss to follow-up. ^[1]

Staged pathway (Six Core Elements). Begin with a written transition policy introduced by early adolescence and normalised with the family. Track every eligible young person so none age out unseen. Assess readiness yearly with a validated tool and use the result to teach missing skills. Plan by producing a portable summary and emergency plan, searching for adult providers, and starting legal and insurance work. Transfer with a warm handoff to a named adult home, confirming the first appointment is booked. Complete with post-transfer follow-up confirming engagement. ^{[1] [4]}

Transfer package. Portable medical summary (diagnoses, problem list, history, baseline results), medication and allergy list, written emergency or safety plan (sick-day and insulin rules, hypoglycaemia plan, who to call), condition-specific care and outstanding surveillance, and key contacts with the young person's goals and preferences. The goal is that adult care inherits a complete picture and the young person keeps a safety net. ^[1]