Building Bridges: Developing and Implementing a New Transition to Adult Care Program for Youth with Complex Healthcare Needs at a Canadian Children’s Hospital
Bibliographic record
Abstract
Background/Objectives: Transitioning from pediatric to adult services can be challenging for youth with complex chronic health conditions, especially those with multi-morbidity. These youth often require extra coordination and support during this phase of their healthcare journey. Building upon existing provincial and national initiatives for transitions from pediatric to adult healthcare services, we have developed a hospital-wide program within one of Canada’s largest children’s hospitals that incorporates an integrated care model aimed at better serving these patients and improving outcomes. Methods: Guided by provincial quality standards, an environmental scan and knowledge user engagement were conducted to develop the program, followed by an implementation phase, where the model was piloted. Ongoing learnings from the pilot continue to inform program implementation and evaluation. Results: The Transition to Adult Care (TAC) program offers disease-agnostic care to youth with complex needs for 1–3 years, including 1-year post-transfer, addressing the fragmentation of care across multiple services, organizations and providers. Our interdisciplinary team works in partnership with youth and caregivers to deliver transition navigation, easing the burden on patients and families by tailoring transition supports to each individual youth and caregiver. Preliminary data from the pilot revealed a lack of awareness about transition resources and timelines; however, with early engagement and flexible support beyond age 18, youth were able to complete their transition successfully. Conclusions: The TAC program demonstrates a systems-level approach to improving transition to adult care for youth with complex health needs by integrating individualized support, cross-sectoral collaboration, and continuous quality improvement. Early engagement, flexible post-transfer support, and close partnership with youth, caregivers, and providers are key to facilitating transition. These learnings can inform broader implementation efforts and help address persistent gaps in transitional care across healthcare systems.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.005 | 0.005 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.009 | 0.002 |
| Scholarly communication | 0.002 | 0.001 |
| Open science | 0.003 | 0.005 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.005 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".