Evaluation of the mental health transition navigation model in child and adolescent mental health settings: findings from a pre-post, mixed-methods study

Abstract

Most youth do not experience a coordinated and planned transition out of child and youth mental health services, which often results in discontinuity in mental health care. This gap in care has led to the development and uptake of novel interventions, such as the transition navigation model, to facilitate mental health care transitions. The transition navigation model is a research-informed intervention that aims to assess and improve youth’s transition readiness, identify their transition needs and goals, and support the transfer of care to adult or community mental health services. To evaluate the ongoing implementation of this model, we conducted a pre-post mixed-methods study involving youth participants accessing transition navigation services at two hospitals. Participants (n = 43) completed self-report measures on transition readiness, daily functioning, and mental health service use at baseline and 6-month follow-up. Twenty participants also completed qualitative interviews focused on understanding their experiences and satisfaction with the navigation service. Results indicate a significant increase in participants’ mean transition readiness score and a decrease in the number of emergency department visits from baseline to the 6-month follow-up. However, there were no significant changes in mean functioning scores or self-reported mental health symptoms. The quantitative and qualitative findings converged, indicating overall high satisfaction with the navigation service, with the primary gap in the service being the lack of communication maintained with youth while in the program.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00787-025-02872-w.

Nearly one in five youth (ages 15–24) experience a mental illness [1–3] and approximately 75% of mental illnesses have their onset before the age of 25 years [4, 5], reflecting a substantial need for access to mental health (MH) services among youth. As most mental illnesses persist from adolescence into adulthood [4], youth often require ongoing MH care. Central to ensuring continuity of care for youth is planning and facilitating a coordinated transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) around the age of 18 [6, 7].

Youth who have transitioned out of CAMHS often describe this experience negatively, reporting a lack of transition preparation, planning, and collaboration between CAMHS and AMHS [8–10]. These practices can result in discontinuity of care for youth; one systematic review found that only 24% of youth transitioned to AMHS after reaching their CAMHS age boundary, despite there being a higher proportion of youth requiring ongoing MH care [11]. Youth who do not successfully transition to AMHS report difficulties in maintaining their MH, including challenges in accessing and taking their medication [12]. A coordinated transition of care from CAMHS to AMHS ensures that youth receive the necessary support during a critical service change, potentially reducing unnecessary hospital admissions and emergency department (ED) visits [13]. In recognition of the scope and impact of this service discontinuity, models of transition care have been developed and implemented to facilitate youths’ transitions in MH care [14, 15].

One such model that has been increasingly implemented in MH settings is the transition navigator intervention [15, 16]. Transition navigators support youth as they transition out of CAMHS by evaluating and enhancing their transition readiness, focusing on the development of self-management skills and the knowledge needed for success in AMHS [17]. Transition navigators, who typically have a social work background, receive referrals for youth up to the age of 18 from their primary MH care provider (i.e., psychiatrist, nurse). Typically, navigators work with youth and their caregiver (if preferred by the youth) for a period of up to six months, although the length of service and frequency of meetings vary by program [17]. They collaborate with youth (and their caregiver if involved) to create individualized transition plans based on the youth's unique needs to ensure continuity of care with appropriate AMHS [17, 18]. The role of the navigator may also include case management, system navigation, client advocacy, and brief individual and/or family therapy [17, 18].

Transition navigation models have been found to be effective in facilitating healthcare transitions for youth with physical health conditions (e.g., sickle cell disease [19, 20]). Recently, a randomized controlled trial (RCT) was conducted to evaluate the impact of a navigation intervention on youth transitioning out of pediatric health clinics, including MH clinics [21]. Samuel et al. [21] assessed emergency department (ED) visits as the primary outcome and found a 25% reduction in ED visits among participants with MH comorbidity who received navigation support. While this finding highlights the promising impact of navigation model on youth with MH concerns, further research is needed to evaluate its effectiveness at MH settings due to the limited number of youth (n=13) recruited from MH clinics and lack of assessment of important patient outcomes (e.g., transition readiness, care satisfaction) as part of the RCT. Furthermore, given the identification of transition navigation as a best practice to facilitate transitions [22] and its ongoing implementation in MH services [23, 24], robust evaluations of the model are required.

Therefore, the aim of the Navigator Evaluation Advancing Transitions (NEAT) study was to evaluate transition navigation services at two hospital-based CAMHS using a pre-post, mixed-methods study design [25]. The primary objective of this study was to measure changes in youth's transition readiness, as readiness assessment and improvement form a core priority in facilitating MH care transitions globally [26, 27]. The secondary objectives of this study were to: (1) examine whether working with the navigator supported improvements in youth functioning, MH symptoms, health-related quality of life (QoL), and frequency of ED visits, and (2) to qualitatively understand youth's experiences and satisfaction with the transition navigation service.

Methods

This study utilized a convergent parallel mixed-methods design [28] in which quantitative and qualitative data were collected simultaneously, analyzed independently, and then converged during the interpretation stage. Following a pre-post design, quantitative data were collected from participants at baseline (referral to navigator) and at 6-months following the referral. Qualitative data were collected at the 6-month follow-up.

Participants and recruitment

Data were collected between March 2022 and September 2023, and all participants were recruited from child and adolescent psychiatry programs at a large community hospital and a pediatric hospital in Toronto, Canada. Research ethics board approvals were obtained at both sites. The inclusion criteria for the study were as follows: (1) age 16–18 years, (2) receiving transition navigation services, (3) able to speak, read and write English and (4) able to provide informed consent.

Eligible youth were invited to participate in the study during their first scheduled appointment with the navigator. If the youth was agreeable, a research assistant (RA) would meet with the youth to provide further study information, complete the informed consent procedure, and administer the baseline survey package. Participants were provided with a $40 honorarium.

The navigator shared the study information with 79 youth at their intake appointment, out of whom 60 youth expressed their interest in participating. The RA contacted and obtained consent from 51 youth; of those, 4 consented but did not complete the baseline measures. For the qualitative component, participants who completed the 6-month quantitative assessment and consented to be contacted for the qualitative interviews were all invited to participate, a total of 20 youth consented and participated.

Quantitative measures

All quantitative measures were administered at baseline and at the 6-month follow-up, except the two Experience of Care measures, which were only administered at the 6-month follow-up. Details regarding the psychometric properties of each measure is described in supplementary file one.

Demographics

Youth participants reported their demographic characteristics including age (in years), sex assigned at birth, gender identity, sexual orientation, living situation, school and/or work hours, and self-reported mental and physical health diagnoses.

Transition readiness

The 20-item Transition Readiness Assessment Questionnaire (TRAQ) [29] was used to assess five subscales of transition readiness, including: Managing Medications, Appointment Keeping, Tracking Health Issues, Talking with Providers, and Managing Daily Activities. Items are scored on a 5-point Likert scale; total and subscale scores are generated, with higher scores indicating greater readiness and ability to negotiate transitions in care.

Symptoms and functioning

The 13-item Columbia Impairment Scale (CIS) [30] was administered to measure global impairment in four major areas of functioning: interpersonal relations with family and friends, broad psychopathological domains, functioning in job or schoolwork, and use of leisure time. Items are summed to produce a total score ranging from 0 to 52; higher scores indicate poorer functioning and a score of ≥ 16 indicates more severe functional impairment [31].

Mental health symptoms were measured using the Youth Self Report (YSR) [32]. The YSR is a 119-item scale which measures eight empirically derived syndromes. To provide population standardization, raw summary scores for each syndrome scale are expressed as T-scores, and a T-score of ≥ 70 indicates clinically-elevated symptoms.

Quality of life

Quality of life was measured using the Assessment of Quality of Life-6D (AQoL-6D) [33, 34], a 20-item assessment of six domains of QoL: independent living, relationships, MH, coping, pain and senses. Scores are combined across the domains to form a single global QoL factor, with higher scores indicating quality of life impairment.

Health service use

An adapted version of the Health and Social Service Utilisation (HSSU) [35, 36] measure was administered to assess the use of health services. Participants are asked to indicate whether they had any ED visits within or outside their recruitment agency in the past 6 months (yes/no). If participants responded ‘yes,’ they were asked to specify the number of ED visits they had.

Experience of care

The Satisfaction with Mental Health Navigator Tool (SMHNT) was used to measure youth satisfaction with the navigator model at 6 months. The SMHNT is an 11-item scale adapted from the Navigation Satisfaction Tool [37]; the first item focuses on the frequency of contact with the navigator, and the remaining 10 items cover aspects of the youth’s satisfaction.

The 27-item Core Components of Effective Youth Transitions (CCEYT) checklist was administered at 6 months to capture core components of stages of effective transitions identified in the literature. The CCEYT has four categories of effective transitions: transition readiness, transition planning, transfer of care, and transfer completion. The CCEYT was validated among youth via a National Delphi consensus study [22].

Qualitative interviews

Semi-structured interviews were conducted with participants (n = 20) to gather insights regarding youth’s experiences with the navigator program. They were asked about their referral process to the program (e.g., Who referred you to the program?), types of support provided to them (e.g., What kind of supports did the navigator provide to you?), and their involvement during the transition process (e.g., Tell me about how you were involved in the discussion and decision about transitioning out of the hospital?). To capture information regarding their satisfaction with the program, participants were asked to describe aspects of the program they did, and did not, find helpful and to discuss their recommendations for improving the program.

Data analysis

Quantitative analyses consisted of descriptive statistics, including frequency distribution and percentages, and Pearson correlations. Paired sample t-tests, chi-square tests, and Wilcoxon signed-rank tests were used to capture change over time on transition readiness, symptoms, and service utilization. All quantitative analyses were undertaken using R, Version 4.3.2 [38]. Two-sided p-values < 0.05 were considered statistically significant. There was minimal missing data within a time point (< 1%), and the study has strong retention across the two time points as 91% of participants completed both the baseline and 6-month follow-up. Complete case analysis was used for the pre-post testing.

Qualitative interviews were transcribed and analyzed in NVivo using a directed content analysis as outlined by Assaroudi et al. [39]. To synthesize findings on the efficacy of the navigator program and youth’s overall satisfaction and recommendations for improvement, quantitative and qualitative data were integrated by comparing and contrasting common elements that were then organized in a joint display [40].

Youth engagement

The research team collaborated with youth advisors (HA & MD) to review and confirm the study design, including the selected study measures. The youth advisors provided feedback on measures that had not been previously validated (CCEYT) or were adapted for this study (i.e., the navigation satisfaction tool [37]). They recommended adding examples to increase clarity and ensure the language was accessible. The youth advisors also contributed to writing and reviewing this manuscript.

Results

Participant characteristics

A total sample of 47 youth completed the baseline assessment. Of those, 4 youth did not complete the 6-month follow-up resulting in 43 with complete data. At baseline, 60% of participants were 17 years old, 74% were assigned female at birth, 64% identified as a woman, and 40% identified as heterosexual. The most common self-reported MH diagnosis was anxiety disorder (81%) followed by mood disorder (55%). Table 1 presents a full description of the sample.

Table 1.

Demographic characteristics

	Total (n = 47)	Completed Baseline and Follow-Up (n = 43)	Dropped at Follow-Up (n = 4)
Sex assigned at birth
Female	35 (74.5)	31 (72.1)	4 (100.0)
Male	12 (25.5)	12 (27.9)	0.0
Gender identity
Cis woman	30 (63.8)	27 (62.8)	3 (75.0)
Cis man	11 (23.4)	11 (25.6)	------
Another identity (e.g., non-binary, trans, gender fluid, gender queer)	6 (12.8)	5 (11.6)	1 (25.0)
Language
English	36 (76.6)	33 (76.7)	3 (75)
French	2 (4.3)	2 (4.7)	------
Another language	9 (19.1)	8 (18.6)	1 (25)
Spanish	3(6.4)	3 (7.0)	------
Portuguese	2 (4.2)	2 (4.7)	------
Russian	1 (2.1)	1 (2.3)	------
Arabic	1 (2.1)	------	1 (25)
Vietnamese	1 (2.1)	1 (2.3)	------
Sinhala	1 (2.1)	1 (2.3)	------
Sexual orientation
Straight/heterosexual	19 (40.4)	18 (41.9)	1 (25.0)
Bisexual	11 (23.4)	11 (25.6)	-----
Lesbian/Gay/Queer	5 (10.6)	4 (9.3)	-----
Another identity not already listed	12 (25.5)	10 (23.3)	3 (75.0)
Age
16	8 (17.0)	6 (14.0)	2 (50.0)
17	28 (59.6)	28 (65.1)	2 (50.0)
18	11 (23.4)	9 (20.9)
Cultural group identity
White (Canadian, European)	19 (40.4)	18 (41.9)	1 (25.0)
Black (Canadian, African, Caribbean)	2 (4.3)	2 (4.7)	-----
Asian	13 (27.7)	10 (23.3)	3 (75.0)
Latin American	5 (10.6)	5 (11.6)	------
Mixed	4 (8.5)	4 (9.3)	------
Another identity not already listed	2 (4.3)	2 (4.6)	------
Prefer to not answer	1 (2.0)	1 (2.3)	------
Do not know	1 (2.0)	1(2.3)	------
Current living situation
With parent(s)/family home	40 (85.1)	36 (83.7)	4 (100.0)
Not in family home	7 (14.9)	7 (16.3)	-----
Currently enrolled in school
Yes	45 (95.7)	41 (95.3)	4 (100.0)
No	2 (4.3)	2 (4.7)	-------
Any work for pay in past 4 weeks
Yes	12 (25.5)	11 (25.6)	1 (25.0)
No	35 (74.5)	32 (74.7)	3 (75.0)
Mental health diagnosis
Anxiety Disorder	38 (80.9)	36 (83.7)	2 (50.0)
Mood Disorder	26 (55.3)	23 (48.8)	3 (75.0)
Psychotic Disorder	0.0	0.0	0.0
Personality Disorder	1 (2.1)	1 (2.3)	0.0
Eating Disorder	5 (10.6)	4 (9.3)	1 (25.0)
Neurodevelopmental Disorder	19 (40.4)	17 (39.5)	2 (50.0)
Behavioral Disorder	2 (4.2)	2 (4.6)	0.0
Substance Use Disorder	2 (4.2)	2 (4.6)	0.0
Another diagnosis not already listed	1 (2.1)	1 (2.3)	0.0
Prefer not to answer	2 (4.2)	2 (4.6)	0.0

Quantitative results

Descriptive statistics for the TRAQ, YSR, and SMHNT at baseline and follow-up are reported in Tables 2 and 3, and 4, respectively.

Table 2.

TRAQ mean change from baseline to 6-month follow-up

	Baseline	6-Month Follow-up
	M(SD)	M(SD)	Diff (95% CI)	t(42)	P
Managing Medications	3.69(1.0)	3.99(0.92)	0.30 (0.01, 0.58)	2.11	0.041
Appointment Keeping	3.07(0.73)	3.33(0.75)	0.26 (0.06, 0.46)	2.58	0.014
Tracking Health Issues	3.50(0.83)	3.84(0.85)	0.34 (0.04, 0.64)	2.30	0.027
Talking with Providers	4.55(0.56)	4.57(0.67)	0.02 (−0.18, 0.22)	0.233	0.817
Managing Daily Activities	4.16(0.83)	4.40(0.64)	0.25 (0.08, 0.42)	2.96	0.005
Total	3.57(0.61)	3.85(0.62)	0.28 (0.11, 0.45)	3.27	0.002

Table 3.

Youth Self Report syndrome scales mean change from baseline to 6-month follow-up

	Baseline	6-Month Follow-up
	M(SD)	M(SD)	Diff (95% CI)	t(df)	p
Anxious-Depressed	70.88(11.20)	67.98(11.79)	−2.90 (−5.95, 0.14)	−1.93(41)	0.061
Withdrawn-Depressed	66.72(9.90)	65.65(10.18)	−1.07 (−3.10, 0.96)	−1.06(42)	0.294
Somatic Complaints	63.74(9.02)	60.14(9.37)	−3.60 (−6.10, −1.09)	−2.90(41)	0.006
Social Problems	62.88(8.13)	63.50(9.09)	0.62 (−1.43, 2.67)	0.61(41)	0.545
Thought Problems	65.72(9.27)	63.30(8.71)	−2.42 (−4.91, 0.07)	−1.96(42)	0.056
Attention Problems	67.35(12.45)	66.45(11.90)	−0.90 (−3.97, 2.16)	− 0.60(41)	0.554
Rule-breaking Behaviour	58.46(7.53)	58.30(6.61)	−0.16 (−1.90, 1.57)	− 0.19(42)	0.851
Aggressive Behaviour	56.62(7.44)	56.40(7.27)	−0.22 (−2.04, 1.61)	− 0.24(42)	0.814

Table 4.

Characteristics of SMHNT and pearson correlation coefficients with global variables

		Global Variables
Navigation items	M(SD)	Likelihood of recommending service	Overall satisfaction
How satisfied are you with the Navigator’s ability to listen and understand your concerns?	5.3(1.7)	0.72**	0.84**
How satisfied are you with the information given to you about potential treatment options (e.g., possible outpatient clinics, family doctor, etc.)?	5.2(1.7)	0.65**	0.83**
How satisfied are you with how the Navigator understood the impact of your mental health on your wellbeing and service needs?	5.4(1.8)	0.73**	0.84**
How satisfied are you with how the Navigator maintains your confidentiality (e.g. keeping personal health information private)?	6.3(1.5)	0.48*	0.68**
How satisfied are you with how the Navigator respects your rights (e.g. right to be treated with respect, right to effective communication)?	6.2(1.2)	0.52**	0.71**
How satisfied are you with the intake procedures (e.g. collecting key pieces of information from you prior to your first appointment, such as contact information, medical history, and payments)?	5.7(1.5)	0.56**	0.62**
How satisfied are you with your type of contact (e.g. phone calls, in-person, virtual, email, etc.) with the Navigator?	5.8(1.4)	0.55**	0.61**
How satisfied are you with the frequency of contact you had with your Navigator?	4.9(1.9)	0.55**	0.80**
Overall, how satisfied are you with the Navigator? a	5.4(1.8)	0.73**	--
How likely are you to recommend these navigation services to friends and family if they needed similar care or treatment? a	3.6(1.4)	--	0.73**
Frequency of contact b
Less than once every two months	18 (41.9%)
Once every two months	7 (16.3%)
Once every month	3 (7.0%)
Once every three weeks	3 (7.0%)
Once every two weeks	7 (16.3%)
Once per week	4 (9.3%)
More than once per week	1 (2.3%)

All items were measured on a Likert-type scale from 1 to 7, except likelihood of recommending service, which was measured on a Likert-type scale from 1 to 5

*p <.05, **p <.001

^aGlobal variables

^bThis item was measured on a Likert scale from 1 (less than once every two months) to 7 (more than once per week)

The overall TRAQ score and four of the five subscale scores were significantly higher at 6-month follow-up compared with baseline (see Table 2). There was no significant change over time in the subscale “Talking with Providers”.

There was no significant change in CIS mean scores from baseline (M = 20.02, SD = 8.1) to 6-month follow-up (M = 19, SD = 7.9); p =.32. Clinically impaired functioning (CIS score of ≥ 16) also did not change over time X² (1, N = 43) = 0.85, p =.35. The only change in syndromes scores assessed by the YSR was Somatic Complaints, which significantly decreased from baseline to the 6-month follow-up (Table 3).

A significant increase was observed in the total AQoL-6D from baseline (M = 65.06, SD = 11.56) to the 6-month follow-up (M = 68.41, SD = 12.44), t(42) = 2.54, p =.01, indicating better QOL.

Median number of ED visits significantly decreased from 3 at baseline (IQR = 4.5) to 1 at the 6-month follow-up (IQR = 1), p =.034.

Based on the SMHNT, satisfaction with the navigator program at follow-up was largely positive, with an overall mean satisfaction of 5.4(SD = 1.8) out of a possible score of 7 (Table 4). Global satisfaction was most strongly correlated with the following items: navigator’s ability to listen and understand concerns, the information provided about potential treatment options, and the navigator’s understanding of the impact of the youth’s MH on well-being and service needs. The largest portion of youth (41.9%) reported contact with the navigator less than once every two months, while a minority contacted the navigator once per week (9.3%).

Using the CCEYT, participants overall reported high agreeability regarding the extent to which the core components of transition were implemented by their navigator. The mean score based on components within the four categories is as followed: transition readiness (M = 2.2, SD = 0.94), transition planning (M = 2.2, SD = 0.84), transfer of care (M = 2.6, SD = 1.2), and transfer completion (M = 2.8, SD = 1.4), with lower scores representing higher agreement.

Qualitative results

Three themes and nine corresponding subthemes were identified (Table 5). Themes one and two highlight the navigator’s support in preparing for the youth’s transition and connecting the youth to MH care respectively. The third theme focuses on operational gaps within the navigation program noted by participants. A representative quote for each subtheme is included in Table 5, with additional quotes available in Supplementary File 2.

Table 5.

Qualitative themes with representative participant quote for each subtheme

Themes	Subthemes	Representative Quote
The navigator’s role in preparing for youth’s transition	Start the transition process before the youth turns 18	“So, maybe start a little bit earlier, before I turn 18, that would have been nicer because maybe I would have been able to get into the DBT thing.”
	Provide youth with information regarding adult mental health services	“And then when it came to discussing my treatments elsewhere regarding my mental health, it was helpful to have [the Navigator] kinda give me the understanding of how care looks like when you’re no longer a child, because the care you receive in peds is very different from the [adult mental health] care.”
	Collaborate with youth’s child and adolescent mental health team	“So. the communication was really good between me and my psychiatrist, and my team, even [Navigator], she was attending some of our sessions… instead of me having multiple appointments to make, just having [substance use care provider], my psychiatrist and [Navigator] all in the same call.”
The Navigator’s role in identifying and connecting youth with mental health care	Search and provide youth with mental health care options	“Like, it centered around location, like mental health services here, but also my university has services. So, they were able to find phone numbers and links from the websites and then give them to me.”
	Review mental health care options with youth	“The follow up appointments or meetings were definitely talking more about the referrals, and what would stand out to me as in terms of where I want to access my care.”
	Send referrals to mental health agencies	“Ah, yeah, I think the navigator’s generally someone who kinda connects everything together. So, I think they’re the ones - they’re probably in the best position to send the referral.”
	Check in with youth to confirm access to the new agency	“Um, I did have one check-in, which was a week or so after I had the intake. And that was helpful just with getting the confidence to get into private therapy.”
Operational gaps within the navigation program	Lack of consistent communication maintained during the program	“I feel there should be more, like, check-ins… and follow-ups in terms of - so, in my case, [Navigator A] was following up more about the referral for adult psychiatry, it would definitely help me understand what’s happening and where it’s at.”
	Disruption in navigation services	“I just thought that was very strange, that I was referred to see somebody, and I ended up having to tell them my entire story at [Site A], even though everybody knew they were leaving, like the next day.”

Theme 1: The navigator’s role in preparing for youth’s transition

Participants described ways the navigator assisted them in preparing for their transition out of CAMHS. This included the navigator maintaining communication with their CAMHS clinician to discuss continuity of care plans and participating in joint meetings with their CAMHS clinicians, which helped youth to avoid having multiple meetings. Participants reflected upon the need for and importance of receiving information regarding AMHS to help them prepare for their transition. For example, some participants felt the information gave them a realistic perspective of what to expect in AMHS, while others wished they had received more details about available services (e.g., regarding the frequency of appointments).

Many participants stated that it would have been helpful if the transition process, including sending referrals to adult care, would have happened earlier. Participants specifically stated that it would have been helpful to start the transition process before age 18 to ensure that they were connected to other services after they had to transition out of CAMHS.

Theme 2: The navigators’ support with identifying and connecting youth with mental health care

Multiple participants reported that the navigator extensively searched for, and provided them with, a list of MH care options (e.g., list of community and hospital-based MH programs). The options shared were based on youth’s preferences (e.g., service location) and needs (e.g., support at school) discussed during their appointments, with most describing this as a positive experience. Participants reflected on the process of reviewing these options and selecting programs and services with the navigator, most reporting they were given autonomy to make the selections they desired. Participants shared that navigators sent referrals to MH agencies (i.e. AMHS and community agencies), which was described as helpful. However, a few participants reported that their navigator did not complete the referral but rather provided them with information on suggested services to contact independently. These participants described wanting their navigator to be more hands-on and active in the referral process. A few participants also reported that the navigator checked in with them following their initial appointment with the new provider.

Theme 3: Operational gaps within the navigation program

Participants voiced concerns over the lack of communication maintained and the disruption in navigation services due to staffing changes. Many participants felt that their navigator should have maintained consistent communication during the transition process. A majority of them also experienced a discontinuation of navigation services due to staffing changes in the navigator role. They attributed this as a negative experience as it left them without navigation support and led to them having to repeat their story with the new navigator.

Mixed methods results

Quantitative and qualitative data sets were converged in a joint display (Table 6). For all topics there was substantial convergence of findings. Integrated findings suggest that navigation services support youth in transitioning from CAMHS to AMHS by helping them develop essential skills and connecting them to relevant services, with frequent communication being crucial to their satisfaction with the transition process.

Table 6.

Joint display

Topic	Quantitative Findings	Qualitative Findings	Convergence or Divergence	Interpretations
Navigators can enhance transition readiness	● Overall transition readiness and four subscale scores significantly increased from baseline to 6-month follow-up. ● Youth agreed that their navigator conducted regular transition readiness assessments.	● Navigators helped youth to understand how AMHS differ from CAMHS ● There was strong collaboration between the navigator and other health care providers	Convergence	Navigation services prepare youth to transition from CAMHS to AMHS by building service knowledge, AMHS understanding, and daily living skills, among others.
Comprehensive support and effective communication by navigators enhance youth satisfaction	● Satisfaction with the navigator program was largely positive, driven by the navigator’s listening skills, treatment information, and understanding of the impact of mental health on service needs.	● Navigators provided information regarding available mental health services ● Navigators sent referrals to mental health agencies on behalf of youth	Convergence	Navigators can enhance youth satisfaction by listening to the youth’s needs and providing information and referrals to services.
Challenges with communication and contact frequency impact navigation service	● Most youth contacted their navigator less than bi-monthly, while a few did so weekly.	● Youth discussed a lack of consistent communication with their Navigator	Convergence	Youth value open, frequent communication with their Navigator. When there is limited or inconsistent contact, youth feel less supported in the service.

Discussion

Based on the study findings, transition navigation is a promising model of care to facilitate youth’s transition out of CAMHS. Participants’ TRAQ scores significantly improved from baseline to six-month follow-up, validating an important focus of the navigator model, assessing and enhancing youth’s transition readiness for adult services [22, 27]. The navigator programs evaluated in this study prioritized information sharing with youth. Youth reported that the navigator provided them with extensive information regarding multiple MH resources, including the type of program (e.g., outpatient, school-based) and the funding nature of the program, with an aim to improve transition readiness.

Interestingly, we found an improvement in the overall TRAQ and all subscales’ scores except the ‘talking with provider’ subscale. Participants in this study had high scores (4.55/5) on the ‘talking with provider’ subscale at both baseline and follow-up. Previous research has also identified higher scores on this subscale among youth with chronic physical and mental health conditions [41, 42], youth who have been regularly accessing mental health care ahead of the navigation intervention may have already developed strong skills related to communication with their providers, reducing the need to focus on developing this aspect of transition readiness when working with the navigator.

Participants’ MH symptoms and functioning levels did not change from baseline to 6 months, aligning with existing research. Mitchell et al. [43] conducted a randomized controlled trial (RCT) to evaluate a discharge intervention that included providing navigation support to hospitalized patients with depressive symptoms. They also found no changes in depressive symptoms at the 30-day follow-up. We did, however, find a significant reduction in ED visits by participants over the 6-month period, which is promising given ED visits can represent gaps in MH care [44, 45] and a high cost to the health care system [46]. Navigators often focus on developing a comprehensive transition plan with youth that aims to ensure they know how to connect with MH services when in need, thereby reducing the need for them to present to the ED. Given MH-related ED visits by youth have steadily increased over the past decade [47, 48], particularly among transition-aged youth [47–50], this reifies the purpose of interventions like the Navigator model that can mitigate ED use by either maintaining continuity of care or connecting youth with appropriate MH services and/or resources that can be accessed before issues escalate.

High staff turnover in some CAMHS settings may pose a significant challenge to ensuring continuity of care [17, 51]. A key finding from the qualitative interviews was that multiple participants experienced disruption in navigation services, and ultimately the transition process, due to staff turnover. Research shows that staff turnover evokes feelings of anxiety and distress among patients [52], which reflects the experience of participants in this study. Programs implementing the model should consider how to address and account for staff absences (planned or unplanned) and turnover, such as having alternative contacts and prioritizing warm hand-offs when staff are away or leave their position.

Strengths and limitations

The mixed-methods research design is a primary strength of this study, as it allowed for data triangulation and supported a comprehensive evaluation [53]. The use of validated measures that have been recommended for use in this population [54, 55], including the TRAQ [42] and CIS [56], further strengthened this evaluation. Lastly, we conducted evaluations at two diverse hospital sites, permitting assessment of the implementation of the navigation model across settings. This study was set up as an evaluation study, and powered for the primary outcome as described in our protocol [25]. However, sample size limits our ability to control for covariates and parse out further differences in demographics (e.g., location of service, sex, and gender). The current sample does not allow for an examination of the impact of navigation for youth with different diagnoses or symptom acuity at baseline, which should be incorporated into ongoing evaluation of the intervention. Finally, we collected and analyzed self-reported data, including MH diagnoses and ED visits, which are susceptible to recall bias. Future research should include utilizing the electronic health records to confirm diagnosis, wherever possible.

Implications for research and practice

We successfully recruited our target recruitment sample and had a high participant retention rate (91%) across the two timepoints of this study, demonstrating feasibility of this type of evaluation and supports the need for a more fulsome of the transition navigation model. Specifically, RCTs could be implemented in future evaluations of transition navigation services to comprehensively examine the efficacy of the model. This study can provide the estimates that can be used to power an RCT and appropriate outcome measures selection. To our knowledge, no RCTs have been previously conducted on the transition navigation model to support youth transitioning out of CAMHS.

Results in the primary outcome (improved TRAQ scores) combined with decreased ED visits and patient-reported satisfaction with the model indicate it is likely a promising practice that would benefit from greater integration across CAMHS. Implementation of this model across CAMHS would be supported via toolkits [57], which aim to provide a comprehensive overview of the model and include workbooks to support uptake in different service settings [58].

Conclusion

This study found an increase in participants’ transition readiness and reduction in ED visits from baseline to 6-month follow-up. We also found that participants MH symptoms and functioning levels maintained overtime. While larger studies are needed, these findings suggest that the transition navigation model may effectively support youth during their transition out of CAMHS. Future research on this model is needed to support the uptake and implementation of the model across various CAMHS.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

K.C., S.S., J.D. and L.E. wrote the main manuscript text, S.B. and L.E. conducted the statistical analysis and prepared all analytical tables, S.S. and K.C. conducted the qualitative analysis and conducted the mixed methods analysis and joint display table. All authors (K.C., S.S., L.E., J.D., H.A., M.D., S.B., S.N., K.L., A.C., S.M., D.K.) reviewed drafts and the final manuscript.

Funding

The NEAT study was funded by the Canadian Institutes of Health Research (CIHR) under grand agreement (TEG-16558). This paper reflects the authors’ views only. CIHR had no role in the study design, analysis, writing and submission of this manuscript.

Data availability

The data are available from the authors upon reasonable request—subject to ethical permissions and participant consent.

Declarations

Ethics approval

Research ethics approval were obtained from the Hospital of Sick Children (1000066139), Michael Garron Hospital (857-2202-Psy-025) and the University of Toronto (00039046).

Consent to participate

All participants in this study provided electronic informed consent via REDCap in accordance with procedures approved by the research ethics boards across sites.

Competing interests

The authors declare no competing interests.