What is the system challenge?

The KFL&A Service Collaborative identified that there was no clear transition pathway to ensure consistent, appropriate and successful transitions from the child and youth mental health sector into adult clinical services for youth who:

are aged 16-24;
live with mental health and/or addictions issues;
require specialized, complex care; and
are not currently engaged in service, or are transitioning between services.

In many cases, TAY with mental health and/or addiction issues and their families are not able to access the right kind of services in the adult system, or they are unable to bridge the gap to adult care and drop out of services altogether.

Evidence:

The TRACK study reviewed transitions from children and adolescent to adult mental health services across the United Kingdom.

The TRACK study: (1) identified organizational factors (such as ineffective implementation of existing protocols, and lack of collaboration and communication between sectors) that interfere with effective transitions, and (2) provided recommendations on how services can be organized and delivered to best support youth transitions.

As part of the recommendation summary, the TRACK study identifies four components for ideal processes and supports for transition:

Information continuity: effective information transfer.
Relational continuity: a period of parallel care and joint working between services.
Cross boundary and team continuity: transition planning with at least one meeting. including the young person, parent/caregiver, youth service provider, adult service provider and other services.
Care continuity: connections between the child and youth and adult service providers after the transition is complete (for at least three months after the transition).

Find more evidence

The KFL&A Service Collaborative, with support from the Provincial System Support Program at the Centre for Addiction and Mental health, developed and implemented the Youth Transitioning Protocol in KFL&A. Known locally as the YTP, the protocol is a step-by-step process that defines and clarifies a transition pathway from child and youth services to adult services. The YTP helps agencies to agree on methods and resources to help youth in this transition, using a coordinated team approach (“transition teams”) and an individualized plan to ensure ongoing success.

Transition teams bring together relevant individuals to help transition aged youth during their transition between services. Team members could include youth and adult service workers, family members, primary health care providers, community support services, clinicians, educators, and other key allies. These teams collaborate to develop a youth and family-centred individualized plan that ensures a timely and responsive transition for the youth to the appropriate adult services. The transitioning process begins before the youth turns eighteen or as part of the initial assessment process when the youth is already engaged in services.

A companion resource known as the Youth Toolkit was created and designed by youth, for youth. It is meant to help youth communicate their thoughts and concerns with members of their transition team.

The YTP outlines five key transitioning steps to be followed by the youth and adult serving agencies:

Initiate the transition: This is the first step in starting the conversation about the transition where the youth, their family, and current service provider come together to discuss the needs of the youth.
Preparation for transition meeting(s): This is the preparation phase before the transition meetings take place between youth, their families, and service providers.
Transition meeting(s): These meetings serve as an opportunity to identify and address any needs and/or concerns that the youth and families might have and to ensure that the needs can be met by the adult serving agency. These meetings allow the youth to start building relationships with the adult agency and understand the process, roles, and responsibilities of all the service providers involved.
Post meeting(s): These meetings address any outstanding challenges, barriers, or concerns that the youth might have before the final hand-off into adult services takes place.
Final transition phase: The youth and families are now transitioned into the adult agency and will begin to receive services. The adult agency adheres to check-ins with the youth service agencies in order to ensure that the youth is attending meetings and remains and stays engaged in the process.

Exploration
Installation
Initial Implementation
Full Implementation

?What's this?

Initial Implementation

In October 2015, four YTP orientation sessions were held for 140 clinicians from the KFL&A community. The content, facilitation, and relevance of the orientation sessions were well received. A rapid, early evaluation of launching the YTP beyond the pilot to the broader community of providers assessed its status and early impact at three months after implementation.

Full Implementation

Full implementation of the Youth Transitioning Protocol across KFL&A began in January 2016. With the full support of CAMH’s Provincial System Support Program Regional Implementation Team, a Sustainability and Oversight Committee has been established to guide implementation and application of the YTP. The Committee is working with a sustainable evaluation approach, as well as monitoring ongoing implementation. The KFL&A Service Collaborative held its final meeting in March 2016 to celebrate and reflect on the three-year journey to improve the transition experience and clinical outcomes for youth moving into adult services.

How do we know it works?

My hope for the YTP moving forward is that youth and adult serving agencies will continue to work together with and not just for youth to prevent youth in transition from “falling through the cracks”. The YTP has given us the tools to build a bridge over those cracks!
— Service Provider/Partner

The YTP has improved the transitioning experience by preparing young people through empowerment. The YTP asks the young person to identify their team and their goals. It has also bridged youth and adult services to support each young person through their individual and unique transition.
— Service Provider/Partner

50%

of participating service providers found that YTP helped to better support transition-age youth in making a successful transition to adult mental health and addiction services.

2/3

of participating service providers saw the YTP as bringing a more collaborative approach to helping transition-age youth make a successful transition.

Who is involved?

Over 30 area mental health and addictions service providers make up the KFL&A Service Collaborative, including:

Next Steps

The Oversight Committee is working to ensure that the YTP in KFL&A Protocol is followed consistently amongst participating agencies and staff, including adherence to key action steps, collection and use of evaluation data, and implementation of a continuous process for improvement. The Committee is also coordinating ongoing staff training and networking between youth-servicing agencies and adult-serving agencies.