NCT06093386

Promoting Intensive Transitions for Children and Youth With Medical Complexity From Pediatric to Adult Care

• Status: Recruiting
• Phase: N/A
• Study type: Interventional
• Enrollment: 150 (estimated)
• Sponsor: The Hospital for Sick Children · Academic / Other
• Sex: All
• Age: 210 Months – 213 Months
• Healthy volunteers: Not accepted

Summary

Medical advances have allowed many more children and youth with medical complexity (CMC) to survive well into adulthood. However, this has not been matched with increases in knowledge of complex conditions or the availability of supports as they transition into the adult care system. The goal of this randomized control trial is to compare intensive transition support from a transition team, led by an advance practice nurse, during transition to adult care for 2 years, with usual care in CMC. Participants assigned to the intervention group will be offered support in care planning, receiving funding, and connecting with a primary care provider and adult subspecialists. The main questions it aims to answer are: 1. Does intensive transition support improve the patient's continuity of care over 2 years compared with usual care? 2. Will there be differences between intervention and control groups with respect to other outcomes related to the youth/family's satisfaction with care, care coordination, self-care, health service utilization, cost-effectiveness, and quality of life? 3. What are the experiences of youth, parents, the transition team, and other clinicians involved in the intensive transition support process?

Conditions

• Children and Youth With Medical Complexity

Interventions

Type	Name	Description
OTHER	Intensive Transition Support	Participants assigned to the intervention arm will transfer their transition support leadership to a transition team composed of a transition navigator (an advance practice nurse), a nurse navigator (a registered nurse) and a social worker over 2 years to support them through the multiple phases of CMC transitions including guidance, monitoring, planning, care transfer and transfer completion. CMC and their caregivers will be offered support in care planning, receiving funding, and connecting with a primary care provider and adult subspecialists.

Timeline

• Start date: 2023-11-24
• Primary completion: 2026-09-01
• Completion: 2026-09-01
• First posted: 2023-10-23
• Last updated: 2025-05-15

Locations

1 site across 1 country: Canada