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For health care providers

 Transition to adult care is a challenging process for youth with special health care needs. Likewise, adult care providers feel unprepared to care for transferred patients, lacking resources and time to manage the complexity of their medical needs.

Transferred patients are more likely to experience:

  • Loss to follow-up

  • Irreversible health deterioration

  • Increase in co-morbidities

  • Increase in expensive emergency care

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Exclusion criteria

  • Non-resident of Alberta

  • Planning to move out of Alberta in the next 2 years

  • Enrolled in another transition study with a navigator

  • Not transferring during the study period

The Transition Navigator Trial (TNT) is a pragmatic randomized controlled trial evaluating the effectiveness of a patient navigator versus usual care to improve transition outcomes among adolescents. 

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Inclusion Criteria

  • 16-21 years old

  • Has a chronic medical condition

  • Transferring to adult specialty care

  • Transferring within the next 12 months 

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We will compare health utilization, transition readiness scores and patient-reported health status to understand their experience during transition. We will conduct interviews with participants and stakeholders to understand perceptions of the role of the navigators. Lastly, we will evaluate the health care cost impact related to the navigator intervention.

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The navigator service will provide patient-oriented care during transition to adult care. The navigator will focus on:

  • Preparing for transfer

  • Reducing social and economic barriers to healthcare

  • Serving as a health system broker

  • Promoting self-management

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This study will provide urgently needed data to guide providers and policy makers regarding providing coordinated transitional care, directly addressing the call to action in the 2016 Canadian Association of Pediatric Health centers Guideline for Transition.The results will have the potential to change care delivery, improve health outcomes and experiences of young adults transitioning to adult care.

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