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Transition Care Service for young people with chronic illness moving from paediatric to adult health services

The NSW Agency for Clinical Innovation Transition Care Network commenced in 2004. The Network aims to improve the continuity of care for young people aged between 14 – 25 years of age with chronic health problems moving from children’s health services to adult health services.

The NSW Agency for Clinical Innovation (ACI) Transition Care Service is a state-wide care coordination service responsible for supporting young people (aged between 14-25 years) with chronic illness/disability as they move from children’s health services to adult health services. The Service has a Manager, three Transition Care Coordinators and three (part time) Support Workers.They work closely with Trapeze which is the chronic care transition service for Sydney Children’s Hospitals Network.

The ACI Transition Care Coordinators

The role of the ACI Transition Care Coordinator is to improve the continuity of care for young people with chronic conditions as they move from children’s to adult health services. Each Transition Care Coordinator has an active caseload with patients in varying stages of transition.

Coordinators can help young people and their families by:

  • helping to sort out any difficulties in finding or attending an adult health service
  • providing information about adult health services and services in the community
  • providing guidance and support to attend clinics
  • assisting the young person to adjust to a new adult team and a new adult service and the different ways things may be done in the adult service
  • contacting the young person and their family/carers to make sure they have successfully engaged with an adult health service (young people are generally discharged from our service a year after they first attend their adult health service).

They can help health professionals by:

  • helping to find appropriate adult services
  • supporting young  people when they first move to adult health services
  • providing resources to help prepare young people and their families when they first move to adult health services
  • following through and providing feedback once young people have moved to adult health services

Requesting a referral

Referrals to the ACI Transition Care Service can be made by the young person, parents/carer, health professionals, school teachers, case workers and others via the ACI referral form. The eligibility criteria for this service is:

  • The young person is aged between 14 and 25 years,
  • With a chronic illness/disability (excluding a primary diagnosis of mental health) that
  • Requires complex case coordination to transition to adult specialist health services
  • Is a resident of NSW or ACT.

The Transition Care Coordinators support young people with a wide range of medical conditions including Cerebral Palsy, Neuromuscular conditions, Type 1 Diabetes, Epilepsy and rare diseases.

Transition Network Map

Transition Care Coordinator Contacts

South Eastern Area:
Silvana Techera. Phone 9382 5455: mobile 0425 232128;
Email:  Silvana.Techera@health.nsw.gov.au

Western Area:
Paula Carroll.  Phone: 88907787: mobile 0436 323 321
Email: paula.carroll@health.nsw.gov.au

Northern Area:
Angela Myles. Phone: 4925 7866: Mobile 0434361202
Email: angela.myles@health.nsw.gov.au

Transition Care Network

Contact

Rachael Havrlant
A/Manager Transition Care Network