Introduction
Methods
Stage 1: research questions
Stage 2: search strategy
Stage 3: study selection
Title and abstract review
Full-text review
Stage 4: charting the data
Stage 5: collating, summarizing and reporting results
Results
Characteristics of documents
Question 1: operationalization of child to adult mental health transition success
Question 2: core components and indicators
Core elements | Core components | References |
---|---|---|
(1.0) Transition policy | (1.1) Develop an integrated care pathway that describes the steps that make up the transition process | |
(1.2) Develop a transition policy/statement with input from youth and caregiver(s) that describes the program/agencies approach to transitions | ||
(1.3) Develop a needs-led and developmentally appropriate transition protocol that is agreed upon by both CAMHS and AMHS, which includes standards for communication, information sharing and record-keeping | ||
(1.4) Ensure that all staff have the knowledge, skills and training to effectively support the agency/services approach to transitions | ||
(1.5) Determine a clear role for all individuals (youth, caregivers, CAMHS and AMHS staff) involved in the transition process | ||
(1.6) Include young person and their caregiver(s) at all phases of transition and decision-making | ||
(1.7) Establish the process for evaluation and assessment of transition protocol | ||
(2.0) Transition tracking and monitoring | (2.1) Establish criteria and process for identifying youth who will be transitioning in and out of the agency/service | |
(2.2) Establish a transition flow sheet or log book to track youth who transition between CAMHS and AMHS | ||
(3.0) Transition readiness | (3.1) Conduct regular transition readiness assessments, and in collaboration with youth and their caregiver(s), identify needs and goals, update regularly | |
(3.2) Educate youth and their caregiver(s) about differences in CAMHS and AMHS programs and services | ||
(3.3) Develop individualized transition plan in collaboration with youth and their caregiver(s) at least 6 months before planned transition | ||
(4.0) Transition planning | (4.1) Identify all stakeholders involved in the transition | |
(4.2) In collaboration with youth and their caregiver(s), identify a provider (AMHS) | ||
(4.3) Confirm the AMHS agency/service eligibility criteria | ||
(4.4) Discuss optimal timing of transfer with youth and caregiver(s) | ||
(4.5) In collaboration with youth and their caregiver(s), complete and regularly update the individualized transition plan (including, for example: readiness assessment findings, goals and prioritized actions, medical summary, emergency care plan) | ||
(4.6) Identify the most responsible clinician (i.e. transition/key worker) to ensure continuity in relationship and contact person during the transfer of care | ||
(4.7) At least 6 months prior to transfer of care CAMHS clinician initiate transition planning with the AMHS provider, including holding joint working meetings or a period of parallel care; include youth and their caregiver(s) in meetings | ||
(4.8) Develop communication processes with primary care provider (i.e. family physician, nurse practitioner) to ensure they have consistent up-to-date medication and treatment information | ||
(4.9) Provide youth and caregiver(s) with contact information for self-care management resources, culturally appropriate community supports, and community mental health resources | ||
(4.10) Provide community and health resources to the youth and their caregivers, in the event of withdrawal from AMHS service | ||
(5.0) Transfer of care | (5.1) A specific meeting or case conference should be held with all stakeholders (i.e. youth, caregivers, CAMHS and AMHS clinician) to handover care | |
(5.2) Transfer young adult when his/her condition is stable | ||
(5.3) Complete all documents in transfer package (e.g. referral letter, individualized transition plan, medical records), send to adult practice/external agencies, and confirm receipt | ||
(6.0) Transfer completion | (6.1) Most responsible clinician contact the youth and caregiver(s) 3–6 months after last CAMHS visit to confirm transfer to AMHS and offer consultation assistance |