Synopsis
Prepare young people with disability for adult healthcare through developmentally appropriate, person-centred planning, supported self-management, explicit transfer of clinical responsibility and coordination of equipment, medicines, education and social support.
- Transition is a planned developmental process; transfer is the particular event when responsibility moves from paediatric to adult services.
- Start preparation early enough to build skills and resolve service gaps, adapting pace to cognition, condition, family circumstances and local pathways.
- Use one named worker to coordinate health, education, employment, social care, equipment and community participation.
- Meet the young person partly alone when appropriate, ask their priorities and provide accessible information about confidentiality, consent and adult-service expectations.
- Assess self-management by task: knowing medicines, booking appointments, explaining emergencies, ordering supplies and seeking help can develop at different rates.
- Create a concise portable clinical summary with diagnoses, baseline function, communication, medicines, allergies, devices, emergency plans, safeguarding and key contacts.
- Confirm adult acceptance, first appointment, prescribing responsibility, equipment maintenance and contingency cover before paediatric discharge.
- Review attendance and outcomes after transfer and actively re-engage a young person who misses the first adult contacts.
Key red flags
A young person approaching transfer without an identified adult team, named coordinator or shared clinical summary is at high risk of loss to follow-up.
Essential prescriptions, gastrostomy supplies, ventilation consumables or wheelchair support ending at an age boundary requires urgent continuity planning.
Deteriorating adherence, repeated missed appointments or unplanned admission may indicate inaccessible communication, mental distress, coercion or a failing transition pathway.
Disagreement about decision-making must prompt assessment of capacity for the specific decision and appropriate support, not automatic transfer of authority to parents.
New exploitation, financial control, sexual risk or neglect can emerge as social networks and independence change and requires safeguarding action.
A transfer date chosen solely by birthday despite clinical instability or incomplete arrangements should be reconsidered by both services.
Investigation priorities
Identify aspirations, strengths, support needs and barriers across adult life domains.
Management branches
The young person enters adolescence or a service-specific transition pathway.
- Identify a named worker and map every current service and dependency.
- Ask the young person about health, relationships, education and independence goals.
- Assess communication, self-management and family support task by task.
- Create a written action plan with annual or more frequent review.