Part 6: Transitions

Families can expect that Coordinated Service Planning will provide an opportunity for the family and service providers to plan for transitions. Coordinated Service Planning should not duplicate existing processes, but provide an umbrella under which other local processes can be coordinated and inform each other. For example, at key transition points, the Service Planning Coordinator can take the lead in calling inter-professional transition planning meetings and/or initiate conversations with the family about transition goals and needs.

The transition into school will be critical for many children and their families. Service Planning Coordinators will work with preschool service providers and educators to plan for the transition. The Service Planning Coordinator will also provide information about any potential accessibility-related requirements or modifications required to facilitate the child’s participation in school.

The need for Coordinated Service Planning during other transitions such as those related to life events (e.g. birth of a sibling, family moving) will be determined on a case-by-case basis and will similarly include any providers who will be involved both before and after the transition.

Transitions to Adulthood

Planning for the transition to adulthood is a broad, holistic, person-centred process that identifies a young person’s goals for work, further education and life in the community. It outlines the actions that should be taken year by year to help the young person achieve these goals as well as the roles and responsibilities of the young person and others in carrying out these actions.

The intent of transition planning for adulthood is for all who support the young person to work collaboratively to prepare the young person and family for the transition to adulthood. The Service Planning Coordinator will be responsible for initiating the transition planning process at age 14. The transition plan will build on the existing Coordinated Service Plan by identifying the steps needed for the young person to attain their goals until the anticipated time of leaving school. The transition plan will be part of a young person’s Coordinated Service Plan and will be shared with parents, the young person and all relevant providers. The transition plan is a living document that should be updated annually at minimum, or as required when circumstances and needs change.

Like Coordinated Service Planning, transition planning for adulthood brings together the young person and their family, as well as those who support a young person, such as district school boards and educators, community agencies, service providers and health care providers, to plan for the diverse transition needs and desires of the youth and their family. The process should be cross-disciplinary, collaborative, comprehensive and team-based with a focus on the young person’s goals, supports and information needs.

A young person’s transition plan for adulthood will identify:

• Goals for work, further education, and community living that reflect actual opportunities and resources that are likely to be available after the young person with multiple and/or complex special needs leaves school and are likely to be achievable by the young person, given appropriate and available supports;
• Actions that should be taken year by year to help the young person with multiple and/or complex special needs achieve their goals;
• Roles and responsibilities of the young person with multiple and/or complex special needs, family, and others in carrying out these actions;
• Expected outcomes within the planning process that should be evaluated by the integrated transition planning team at regular intervals or as needed; and
• Timelines for the actions.

Actions identified in the transition plan may include:

• Timely application to programs and services;
• Planning for access to available support services and equipment, and exploring possible work placements and/or post-secondary education;
• Investigating options for future financial support; and
• Developing specific skills, such as skills in the independent use of assistive technology, self-advocacy skills, or employability skills.

In 2014, the Ministries of Children, Community and Social Services and Education implemented integrated transition planning with local protocols in place for young people with developmental disabilities who are preparing for adulthood^{footnote 8[8]}.

When a young person with a developmental disability has a Coordinated Service Plan, the Service Planning Coordinator will be responsible for initiating the integrated transition planning process, starting at age 14, in accordance with local protocols and working with the local Integrated Transition Planning lead agency and other partners (see Appendix C).