New model of transition care at SickKids

Effectively transitioning our patients and families to adult services is a crucial part of the care delivered by all of our health care teams at The Hospital for Sick Children (SickKids) and remains one of our most important goals. Through transition care we provide families with emotional support and clinical guidance to help them manage their on-going health needs and navigate the adult health care system.

The Good 2 Go (G2G) transition program has supported clinicians at SickKids by developing tools and resources that guide their work with patients and families, ensuring a successful graduation to adult hospitals and services.
Increasingly, SickKids is seeing more complex patients requiring integrated treatment and planning which is best delivered by their inter-professional health-care teams. Supporting transitions remains an important part of this model and we are now evolving our approach by scaling and spreading the knowledge base of G2G to frontline health-care providers across SickKids. Many are already engaged in this work, using the resources developed by G2G while tailoring their approach to meet the needs of patients and families.

With this expanded expertise across the hospital, we are evolving to a new model that integrates this work with the expansion of our Family Resource Navigation Service, which helps patients and families navigate Ontario’s complex health-care system. It also includes the capabilities of our new electronic health record that allows for more direct communication between patients and providers. We plan to continue all clinical transition services, and use the lessons learned over the past decade as key elements in our approach to discharge and transition planning.

Over the past twelve years, G2G has been instrumental in highlighting the importance of transition care at SickKids and creating resources for staff. As we evolve our current model, we will continue to apply these tools and resources within our new integrated and inter-professional model that will keep transition care at the forefront of SickKids.