Transition Compass

Transition Compass is a national, co-designed research initiative focused on improving how adolescents and young adults with complex medical conditions move from paediatric to adult healthcare services. It responds to a major gap in care for young people whose transition to adult services is often fragmented, poorly coordinated, and associated with avoidable disengagement, morbidity and poorer health outcomes.

The challenge

Adolescents and young adults with chronic and complex medical conditions often have ongoing health, developmental and psychosocial needs that extend well into adulthood. Yet the move from paediatric to adult healthcare is frequently inconsistent and unsupported, with many services lacking structured, developmentally appropriate transition pathways. This can lead to disruptions in care, increased crisis presentations, and poorer long-term outcomes for young people and their families.

Our approach

Transition Compass is a multi-component, consumer-driven intervention co-designed with young people, caregivers and healthcare professionals. Delivered through an interactive digital platform, the intervention combines automated messaging, flexible support from a transition nurse coordinator, and stage-specific psychoeducational resources to build self-management, autonomy and readiness for transfer to adult care. As a disease-generic model, it is designed to work across diagnostic groups while remaining adaptable to different service contexts.

The project is being evaluated through a national, multi-site randomised controlled trial across New South Wales, Victoria and South Australia, including Sydney Children's Hospital Randwick, The Children's Hospital at Westmead, the Women's and Children's Hospital Adelaide, and the Royal Children's Hospital Melbourne. Alongside the effectiveness trial, a mixed-methods implementation evaluation is examining how the intervention works in practice, what helps or hinders uptake, and what is needed for future scale-up.

Key goals

• Improve post-transition engagement with adult specialist healthcare services.

• Reduce unplanned and crisis-driven presentations during and after transfer.

• Strengthen young people's autonomy, self-efficacy and transition self-management skills.

• Understand the contextual and service-level factors that support or hinder implementation.

• Generate practical recommendations to optimise delivery and scale-up across diverse healthcare settings.

Evaluation & impact

Transition Compass includes a theory-informed implementation evaluation guided by the Consolidated Framework for Implementation Research and an Implementation Research Logic Model. The study assesses acceptability, appropriateness, feasibility, adoption, fidelity, coverage and perceived sustainability, while also examining how the intervention influences autonomy, competence and relatedness for young people navigating transition.