Transitioning care of the pediatric recipient to adult caregivers

Health care transition in pediatric neurosurgery: a consensus statement from the American Society of Pediatric Neurosurgeons

OBJECTIVE

The number of children with complex medical conditions surviving to adulthood is increasing. A planned transition to adult care systems is essential to the health maintenance of these patients. Guidance has been established for the general health care transition (HCT) from adolescence to adulthood. No formal assessment of the performance of pediatric neurosurgeons in HCT has been previously performed. No "best practice" for this process in pediatric neurosurgery currently exists. The authors pursued two goals in this paper: 1) define the current state of HCT in pediatric neurosurgery through a survey of the membership of the American Society of Pediatric Neurosurgeons (ASPN) on current methods of HCT, and 2) develop leadership-endorsed best-practice guidelines for HCT from pediatric to adult neurosurgical health care.

METHODS

Completion of the Current Assessment of Health Care Transition Activities survey was requested of 178 North American pediatric neurosurgeons by using a web-based questionnaire to capture HCT practices of the ASPN membership. The authors concurrently conducted a PubMed/MEDLINE-based literature review of HCT for young adults with special health care needs, surgical conditions, and/or neurological conditions for the period from 1990 to 2018. Selected articles were assembled and reviewed by subject matter experts and members of the ASPN Quality, Safety, and Advocacy Committee. Best-practice recommendations were developed and subjected to peer review by external expert groups.

RESULTS

Seventy-six responses to the survey (43%) were received, and 62 respondents (82%) answered all 12 questions. Scores of 1 (lowest possible score) were recorded by nearly 60% of respondents on transition policy, by almost 70% on transition tracking, by 85% on transition readiness, by at least 40% on transition planning as well as transfer of care, and by 53% on transition completion. Average responses on all core elements were < 2 on the established 4-point scale. Seven best-practice recommendations were developed and endorsed by the ASPN leadership.

CONCLUSIONS

The majority of pediatric neurosurgeons have transition practices that are poor, do not meet the needs of patients and families, and should be improved. A structured approach to transition, local engagement with adult neurosurgical providers, and national partnerships between pediatric and adult neurosurgery organizations are suggested to address current gaps in HCT for patients served by pediatric neurosurgeons.

Changes in Psychiatric Diagnoses During the Transition Phase from Childhood to Adulthood in a Group of Patients with Intellectual Disability

Objective:

The journey into adulthood is a critical phase of profound psychological and social change, especially for children with long-term care needs, including those with Intellectual Disability (ID).

:

In this paper, we aim to describe the clinical picture of patients with mild to profound ID during the transition from childhood to adulthood.

Method:

We explored the prevalence of all comorbidities in 53 patients with mild to profound ID before and after transition. We collected information on the services taking care of the person at the time of follow up and about the actual occupation, if any.

Results:

Out of the whole sample of patients, 79% were in touch with an adult health service after transition and about one fifth required care from more than one institution. 81% were currently employed in centres managed by health services. The distribution of main diagnosis and comorbidities both changed (χ2(1, n=42)=116.7; p<.001 and χ2 (1, n=42)=267.4; p<.001, respectively) after the transition to adulthood. Transition to adulthood was characterized by the emergence, as main diagnosis, of psychiatric disorders, as well as by a slight increase of frequencies of comorbidities.

Conclusions:

After transition from childhood to adulthood a change in epidemiology was observed. This may reflect a clinical evolution or a discontinuity in the use of diagnostic labels between paediatric and adult committed services. We propose suggestions for better management of the transition phase.

Transition to Adult Care for Obstructive Sleep Apnea

Obstructive sleep apnea may occur throughout the lifespan, with peak occurrences in early childhood and during middle and older age. Onset in childhood is overwhelmingly due to adeno-tonsillar hypertrophy, while in adulthood, contributors include risk factors, such as obesity, male sex, and aging. More recently, there has been a precipitous increase in the prevalence of obstructive sleep apnea in youth. Drivers of this phenomenon include both increasing obesity and the survival of children with complex medical conditions into adulthood. Appropriate treatment and long-term management of obstructive sleep apnea is critical to ensure that these youth maintain well-being unfettered by secondary comorbidities. To this end, patient engagement and seamless transition of care from pediatric to adult health care systems is of paramount importance. To date, this is an unacknowledged and unmet need in most sleep programs. This article highlights the need for guideline-driven sleep disorder transition processes and illustrates the authors’ experience with the development of a program for sleep apnea.

"They're kept in a bubble": Healthcare professionals' views on transitioning young adults with congenital heart disease from paediatric to adult care

BACKGROUND

Due to medical advances, growing numbers of adolescents with congenital heart disease (CHD) survive into adulthood and transferring from paediatric to adult healthcare. This transfer is significant step in a young person's life, and this study examines the views of Irish healthcare professionals' on how best to manage this transition.

METHODS

Purposeful sampling was used to invite participation by healthcare professionals (HCPs) from a variety of disciplines whose caseloads include adolescents and young adults with CHD. Fourteen professionals participated in semistructured interviews regarding their experiences of the transition process and their recommendations. Data were collected during Spring 2016 and analysed using thematic analysis.

RESULTS

Results indicated that the current approach to transition and transfer could be improved. Professionals identified barriers hindering the transition process such as cultural and attitudinal differences between HCPs dealing with child and adult patients, inadequate preparation and education of patients about their condition, parental reluctance to transfer, and concern about parents' role in on-going treatment. Measures such as better support and education for both the patients and their parents were recommended, in order to facilitate a smoother transition process for all parties involved. Additionally, HCPs identified the need for better collaboration and communication, both between paediatric and adult healthcare professionals and between hospitals, to ensure greater continuity of care for patients.

CONCLUSIONS

Action is required in order to improve the current transition process. Measures need to be taken to address the barriers that currently prevent a smooth transition process for young adult CHD patients. Professionals recommended the implementation of a structured transition clinic to deal with the wide variety of needs of transitioning adolescent patients and their families. Recommendations for future research are also made.

Facilitating transition from children's to adult services for young adults with life-limiting conditions (TASYL): Programme theory developed from a mixed methods realist evaluation

BACKGROUND

Improvements in care and treatment have led to more young adults with life-limiting conditions living beyond childhood, necessitating a transition from children's to adult services. Given the lack of evidence on interventions to promote transition, it is important that those creating and evaluating interventions develop a theoretical understanding of how such complex interventions may work.

OBJECTIVES

To develop theory about the interventions, and organisational and human factors that help or hinder a successful transition from children's to adult services, drawing on the experience, knowledge, and insights of young adults with life-limiting conditions, their parents/carers, and service providers.

DESIGN

A realist evaluation using mixed methods with four phases of data collection in the island of Ireland. Phase one: a questionnaire survey of statutory and non-statutory organisations providing health, social and educational services to young adults making the transition from children's to adult services in Northern Ireland and one Health Services Executive area in the Republic of Ireland. Phase two: interviews with eight young adults. Phase three: two focus groups with a total of ten parents/carers. Phase four: interviews with 17 service providers. Data were analysed seeking to explain the impact of services and interventions, and to identify organisational and human factors thought to influence the quality, safety and continuity of care.

RESULTS

Eight interventions were identified as facilitating transition from children's to adult services. The inter-relationships between these interventions supported two complementary models for successful transition. One focused on fostering a sense of confidence among adult service providers to manage the complex care of the young adult, and empowering providers to make the necessary preparations in terms of facilities and staff training. The other focused on the young adults, with service providers collaborating to develop an autonomous young adult, whilst actively involving parents/carers. These models interact in that a knowledgeable, confident young adult who is growing in decision-making abilities is best placed to take advantage of services - but only if those services are properly resourced and run by staff with appropriate skills. No single intervention or stakeholder group can guarantee a successful transition. Rather, service providers could work with young adults and their parents/carers to consider desired outcomes, and the range of interventions, in light of the organisational and human resources available in their context. This would allow them to supplement the organisational context where necessary and select interventions that are more likely to deliver outcomes in that context.

The Health Care Transition of Youth With Liver Disease Into the Adult Health System: Position Paper From ESPGHAN and EASL

BACKGROUND

Medical advances have dramatically improved the long-term prognosis of children and adolescents with once-fatal hepatobiliary diseases. However, there is no generally accepted optimal pathway of care for the transition from paediatric care to the adult health system.

AIM

The purpose of this position paper is to propose a transition process for young people with paediatric onset hepatobiliary diseases from child-centred to adult-centred healthcare services.

METHODS

Seventeen ESPGHAN/EASL physicians from 13 countries (Austria, Belgium, France, Germany, Hungary, Italy, the Netherlands, Norway, Poland, Spain, Sweden, Switzerland, and United Kingdom) formulated and answered questions after examining the currently published literature on transition from childhood to adulthood. PubMed and Google Scholar were systematically searched between 1980 and January 2018. Quality of evidence was assessed by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system. Expert opinions were used to support recommendations whenever the evidence was graded weak. All authors voted on each recommendation, using the nominal voting technique.

RESULTS

We reviewed the literature regarding the optimal timing for the initiation of the transition process and the transfer of the patient to adult services, principal documents, transition multi-professional team components, main barriers, and goals of the general transition process. A transition plan based on available evidence was agreed focusing on the individual young people's readiness and on coordinated teamwork, with transition monitoring continuing until the first year of adult services.We further agreed on selected features of transitioning processes inherent to the most frequent paediatric-onset hepatobiliary diseases. The discussion highlights specific clinical issues that will probably present to adult gastrointestinal specialists and that should be considered, according to published evidence, in the long-term tracking of patients.

CONCLUSIONS

Transfer of medical care of individuals with paediatric onset hepatobiliary chronic diseases to adult facilities is a complex task requiring multiple involvements of patients and both paediatric and adult care providers.

Development of a clinical transition pathway for adolescents in the Netherlands

AIMS

To explore how young people with juvenile-onset rheumatic and musculoskeletal diseases (jRMDs) and their parent(s) experience care during preparation for the upcoming transfer to adult services, and to develop a clinical transition pathway.

METHOD

A survey was conducted with 32 young people aged between 14 and 20 years with jRMDs, and their parents ( n =33), treated at the department of paediatric rheumatology in a tertiary care children's hospital in the Netherlands.

RESULTS

More than 30% of young people would have liked to discuss topics such as educational and vocational choices in a clinic, but did not get the opportunity. Preparation for transition was poor as was training in self-management skills. One third of parents had feelings of anxiety about the upcoming transfer. Results from the survey and evidence-based principles of transitional care were used to develop the clinical transition pathway. The pathway focuses on starting transition early, developing self-management skills, joint consultations and supporting parents in giving young people control of their clinical care.

CONCLUSION

Care does not currently meet the needs of young people in the process of transition to adult rheumatology services. The clinical transition pathway developed as a result of the study is a tool that may improve this process.

Transfers and transitions between child and adult mental health services

Background

Transfer of care from one healthcare provider to another is often understood as a suboptimal version of the process of transition.

Aims

To separate and evaluate concepts of transfer and transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS).

Method

In a retrospective case-note survey of young people reaching the upper age boundary at six English CAMHS, optimal transition was evaluated using four criteria: continuity of care, parallel care, a transition planning meeting and information transfer.

Results

Of 154 cases, 76 transferred to AMHS. Failure to transfer resulted mainly from non-referral by CAMHS (n = 12) and refusal by service users (n = 12) rather than refusal by AMHS (n = 7). Four cases met all criteria for optimal transition, 13 met none; continuity of care in(n = 63) was met most often.

Conclusions

Transfer was common but good transition rare. Reasons for failure to transfer differ from barriers to transition. Transfer should be investigated alongside transition in research and service development.

Protocol for a cohort study of adolescent mental health service users with a nested cluster randomised controlled trial to assess the clinical and cost-effectiveness of managed transition in improving transitions from child to adult mental health services (the MILESTONE study)

INTRODUCTION

Disruption of care during transition from child and adolescent mental health services (CAMHS) to adult mental health services may adversely affect the health and well-being of service users. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Healthcare) study evaluates the longitudinal course and outcomes of adolescents approaching the transition boundary (TB) of their CAMHS and determines the effectiveness of the model of managed transition in improving outcomes, compared with usual care.

METHODS AND ANALYSIS

This is a cohort study with a nested cluster randomised controlled trial. Recruited CAMHS have been randomised to provide either (1) managed transition using the Transition Readiness and Appropriateness Measure score summary as a decision aid, or (2) usual care for young people reaching the TB. Participants are young people within 1 year of reaching the TB of their CAMHS in eight European countries; one parent/carer and a CAMHS clinician for each recruited young person; and adult mental health clinician or other community-based care provider, if young person transitions. The primary outcome is Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) measuring health and social functioning at 15 months postintervention. The secondary outcomes include mental health, quality of life, transition experience and healthcare usage assessed at 9, 15 and 24 months postintervention. With a mean cluster size of 21, a total of 840 participants randomised in a 1:2 intervention to control are required, providing 89% power to detect a difference in HoNOSCA score of 0.30 SD. The addition of 210 recruits for the cohort study ensures sufficient power for studying predictors, resulting in 1050 participants and an approximate 1:3 randomisation.

ETHICS AND DISSEMINATION

The study protocol was approved by the UK National Research Ethics Service (15/WM/0052) and equivalent ethics boards in participating countries. Results will be reported at conferences, in peer-reviewed publications and to all relevant stakeholder groups.

TRIAL REGISTRATION NUMBER

ISRCTN83240263; NCT03013595 (pre-results).

The Prevocational and Early Employment Needs of Adolescents with Juvenile Idiopathic Arthritis: The Occupational Therapy Perspective

The purpose of the study was to explore the prevocational needs of adolescents with juvenile idiopathic arthritis (JIA) from the perspective of occupational therapists and to examine the role of occupational therapy in addressing these. A questionnaire was distributed to members of occupational therapy organisations (n = 494) to assess the perceived importance of addressing prevocational issues for adolescents with JIA and the respondents' knowledge, confidence and perceived role. The questionnaire was completed by 175 (35.4%) individuals.

The results showed that although the occupational therapists felt that they were an appropriate profession to address the vocational needs of adolescents, they reported limited knowledge and confidence to do so. Significant unmet training needs were highlighted. This study echoes previous calls for vocational issues to be addressed within adolescent rheumatology and provides evidence that occupational therapy is well placed to coordinate this area of need.

Factors influencing transitional care from adolescents to young adults with cancer in Taiwan: A population-based study

Background

To investigate the progress of transition from paediatric to adult health care for patients with cancer in Taiwan’s medical system.

Methods

The data were retrieved from the Longitudinal Health Insurance Database (LHID), which contains the original inpatient and outpatient medical claims data for 1,000,000 enrollees randomly sampled from the NHIRD between 1997 and 2010.

Results

Among the 1,411 cancer patients selected for this study, 98.09 % received adult-oriented therapy before the age of 18. In addition, only 1.91 % of the patients received paediatric-oriented therapy during adolescence. The primary factors that determine whether these patients would receive paediatric-oriented therapy or adult-oriented therapy at an early age were as follows: the age of the patient at the first visit and the performance-level of the hospital (p < 0.001).

Conclusions

Previous studies conducted in developed countries have demonstrated that the unwillingness of patients to switch from paediatric-oriented therapy to adult-oriented therapy being the major obstacle that hinders the transition process. However, this study revealed a different result: the implementation of the National Health Insurance system in Taiwan makes healthcare affordable for the adolescent patients who may not possess adequate knowledge about paediatric health care and may not appreciate paediatric-oriented therapy, thereby hindering the transition process.

There to Here: Young Adult Patients' Perceptions of the Process of Transition from Pediatric to Adult Transplant Care

Background

An increased understanding of the transition process from pediatric to adult transplant care may inform strategies for facilitating the transfer of patients and ultimately improve outcomes of care.

Objective

To explore the transition process from pediatric to adult transplant care from the perspective of young adults.

Study Design

Using a qualitative case study approach, data were collected from transplant recipients through organ-specific focus groups, from transplant coordinators and nurse practitioners through interviews, and from electronic documents. Data were analyzed using an editorial format.

Results

The analysis identified 5 elements of transition: There to Here, Getting Ready, Frame of Mind, Making It Easier, and Giving Back. In addition, threaded throughout the elements were the themes People Are Important, Expectations of Us, and Information We Need.

Conclusions

The transition for young people from a pediatric to an adult transplant center can be difficult and often traumatic. Young adults who transfer to adult care need to be better prepared for the adult center, made aware of the differences, and introduced to team members before the transfer. Transition programs that aim to improve the transition process should be developed for these patients.

Transfer versus Transition: Success in Pediatric Transplantation Brings the Welcome Challenge of Transition

Context

Increasing success with solid organ transplantation in children has increased the numbers of adolescents and young adults who are at an age to transfer to adult healthcare.

Objective

To determine the nature of transfer/transition of adolescents and young adults to adult healthcare.

Design

Using a qualitative approach, 24 young adults provided answers to 12 questions about their transfer to adult healthcare. Responses were compared to identify themes.

Setting

Subjects had been pediatric patients at Children's Hospital of Pittsburgh. Most were transferred to the University of Pittsburgh Medical Center.

Patients

The subjects had received, or were on the list to receive, solid organ transplants and had been transferred within 18 months of the study.

Results

Twenty-four of 37 potential subjects completed interviews. Those who participated were enthusiastic about making a contribution to the transfer process. Most subjects cited difficulty leaving the pediatric system. Challenges included abrupt transfers, insufficient communication between pediatric and adult specialty providers, and becoming “lost to follow-up.” However, there was a consistent, clear statement that subjects preferred being treated as adults. They liked healthcare staff addressing them instead of their parents, being spoken to in an adult manner, and being responsible for their own care. Suggestions for improvement included early introduction of the concept of transition to adult care, providing written material about the transition process, and use of pediatric/adult social work collaboration to provide support for young adults in transition.

From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people

PURPOSE

The objective of this review is to report on recent developments in youth mental health incorporating all levels of severity of mental disorders encouraged by progress in the field of early intervention in psychotic disorders, research in deficiencies in the current system and social advocacy.

METHODS

The authors have briefly reviewed the relevant current state of knowledge, challenges and the service and research response across four countries (Australia, Ireland, the UK and Canada) currently active in the youth mental health field.

RESULTS

Here we present information on response to principal challenges associated with improving youth mental services in each country. Australia has developed a model comprised of a distinct front-line youth mental health service (Headspace) to be implemented across the country and initially stimulated by success in early intervention in psychosis; in Ireland, Headstrong has been driven primarily through advocacy and philanthropy resulting in front-line services (Jigsaw) which are being implemented across different jurisdictions; in the UK, a limited regional response has addressed mostly problems with transition from child-adolescent to adult mental health services; and in Canada, a national multi-site research initiative involving transformation of youth mental health services has been launched with public and philanthropic funding, with the expectation that results of this study will inform implementation of a transformed model of service across the country including indigenous peoples.

CONCLUSIONS

There is evidence that several countries are now engaged in transformation of youth mental health services and in evaluation of these initiatives.

Transition of adolescent and young adult patients with childhood-onset chronic kidney disease from pediatric to adult renal services: a nationwide survey in Japan

BACKGROUND

Transition of adolescent and young adult (AYA) patients with childhood-onset chronic kidney diseases (C-CKD) from pediatric to adult renal services has received increasing attention. However, information on transition of Japanese patients with C-CKD is limited.

METHODS

The Transition Medicine Working Group, in collaboration with the Japanese Society for Nephrology, the Japanese Society for Pediatric Nephrology and the Japanese Society of Pediatric Urology, conducted a retrospective cross-sectional study in 2014 on issues concerning the transition of Japanese patients with C-CKD.

RESULTS

Few institutions in Japan had transition programs and/or transition coordinators for patients with C-CKD. Refusal to transfer by patients or their families, lack of concern about transition and inability to decide on transfer were common reasons for non-transfer of patients still followed by pediatric renal services. Around 25 % of patients who had ended or interrupted follow-up by pediatric renal services presented to adult renal services because of symptoms associated with C-CKD. Patients with various types of childhood-onset nephrourological diseases were transferred from pediatric to adult renal services. IgA nephropathy, minimal change nephrotic syndrome and congenital anomalies of the kidney and urinary tract were the most frequent primary kidney diseases in adult patients with C-CKD.

CONCLUSION

These survey results indicate the need for introduction of transitional care for Japanese AYA patients with C-CKD. Consensus guidelines for the optimal clinical management of AYA patients with C-CKD are required to ensure the continuity of care from child to adult renal services.

Promotion of the Transition of Adult Patients with Childhood-Onset Chronic Diseases among Pediatricians in Japan

The transition of adult patients with childhood-onset chronic diseases (APCCD) from pediatric to adult health-care systems has recently received worldwide attention. However, Japan is lagging behind European countries and North America as this concept of health-care transition was introduced only 10 years ago. In Japan, before the introduction of this concept, APCCD were referred to as "carryover patients," who were often considered a burden in pediatric practice. In the late 1990s, groups composed of pediatric nephrologists, developmental and behavioral pediatricians, pediatric nurses, and special education teachers researching the quality of life of adult patients with chronic kidney disease began to discuss the physical and psychosocial problems of APCCD. In 2006, a group of pediatricians first introduced the term "transition" in a Japanese journal. By 2010, a group of adolescent nurses had begun a specialized training program aimed at supporting patients during the transitional period. In 2013, the Ministry of Health, Labour and Welfare in Japan convened a research committee, focusing on issues related to social, educational, and medical support for APCCD, and the Japan Pediatric Society established a committee for the health-care transition of APCCD and summarized their statements. Moreover, in 2013, the Tokyo Metropolitan Children's Medical Center initiated ambulatory services for APCCD managed by specialized nurses. The concept of health-care transition has rapidly spread over these past 10 years. The purpose of this article is to describe how this concept of health-care transition has advanced in Japan, such that APCCD now experience a positive pediatric to adult health-care transition.

Evaluation of readiness to transfer to adult healthcare: What about the well adolescent?

BACKGROUND

Understanding readiness to transfer from pediatric to adult healthcare is important for all youth; however, research and implementation guidelines in this area have emphasized youth seen in pediatric subspecialty settings. The purpose of this study was to develop an approach for evaluating transition readiness in a primary care setting, collect pilot data that examined the transition readiness of teens in that program, and implement assessments as part of clinical care.

METHOD

Forty boys and girls aged 12-22 were recruited from an adolescent medicine outpatient program in a large children's hospital. The first 10 adolescents provided responses to questions and participated in cognitive interviewing. Questions changed minimally and responses from all 40 participants were combined. After the study visit, a researcher compared participant responses to electronic medical records and coded responses for accuracy. The survey consisted of 41 transition readiness items from previously published measures.

RESULTS

The research team was able to develop a tool to assess transition readiness within a clinical setting. When administered to participants from that program, participants demonstrated poor transition readiness. Modifications were made based on participant feedback and implementation in the clinical setting. Clinicians were successful with administering transition readiness assessments.

CONCLUSIONS

It appears that even in youth who are generally well, transition readiness is low. Transition readiness assessments can be implemented in the primary care setting, and have been useful for guiding clinical care. Additional barriers and next steps will be discussed.

The adolescent liver transplant patient

The rapid development of new diagnostic tests and improved therapy, especially the success of liver transplantation, has changed the outcome for children with liver disease, many of whom survive into adolescence without liver transplantation. The indications for transplantation in adolescence are similar to pediatric indications and reflect the medical advances made in this specialty that allow later transplantation. These young people need a different approach to management that involves consideration of their physical and psychological stage of development. A focused approach to their eventual transition to adult care is essential for long-term survival and quality of life.

Provider awareness alone does not improve transition readiness skills in adolescent patients with inflammatory bowel disease

OBJECTIVE

Adolescent patients with chronic health conditions must gradually assume responsibility for their health. Self-management skills are needed for a successful transfer from adolescent to adult health care, but the development of these skills could be resource intensive. Pediatric providers are already instrumental in teaching patients about their health and may improve these skills. The aim of the study was to evaluate whether informal education of pediatric providers regarding transition improves inflammatory bowel disease (IBD) patient self-management skills.

METHODS

Consecutive patients with IBD older than 10 years who presented to the outpatient setting were administered a survey regarding self-management behaviors in 2008 and 2011. During this time, several conferences on transition were presented to the providers.

RESULTS

In 2008, 294 patients completed the survey (82%) compared with 121 patients (89%) in 2011. The patient groups were comparable with respect to sex (boys 50% vs 42%), mean age (16.7 vs 16.2 years), and type of IBD (Crohn 68% vs 66%). The 13- to 15-year-olds reported calling in refills (11%, 8%, respectively), scheduling clinic appointment (0, 1%), preparing questions (13%, 5%), and taking the main role in talking during clinic visits (15%, 24%). The 16- to 18-year-olds reported calling in refills (13%, 27%), scheduling clinic appointments (9%, 6%), preparing questions (9%, 16%), and taking the main role in talking in clinic visits (36%, 45%). Responsibility for behaviors gradually increases with age, but did not differ significantly between 2008 and 2011.

CONCLUSIONS

Increasing awareness around transition readiness for pediatric providers had an insignificant effect on the self-management skills of patients with IBD. A more formal or structured approach is likely required to improve transition skills in adolescent patients.

'Talking a different language': an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services

BACKGROUND

Organizational culture is manifest in patterns of behaviour underpinned by beliefs, values, attitudes and assumptions, which can influence working practices. Cultural factors and working practices have been suggested to influence the transition of young people moving from child to adult mental health services. Failure to manage and integrate transitional care effectively can lead to young people losing contact with health and social care systems, resulting in adverse effects on health, well-being and potential.

METHODS

The study aim was to identify the organisational factors which facilitate or impede transition of young people from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) from the perspective of health professionals and representatives of voluntary organisations. Specific objectives were (i) to explore organizational cultures, structures, processes and resources which influence transition from child to adult mental health services; (ii) identify factors which constitute barriers and facilitators to transition and continuity of care and (iii) make recommendations for service improvements. Within an exploratory, qualitative design thirty four semi-structured interviews were conducted with health and social care professionals working in CAMHS and AMHS in four NHS Mental Health Trusts and four voluntary organizations, in England.

RESULTS

A cultural divide appears to exist between CAMHS and AMHS, characterized by different beliefs, attitudes, mutual misperceptions and a lack of understanding of different service structures. This is exacerbated by working practices relating to communication and information transfer which could impact negatively on transition, relational, informational and cross boundary continuity of care. There is also evidence of a cultural shift, with some positive approaches to collaborative working across services and agencies, involving joint posts, parallel working, shared clinics and joint meetings.

CONCLUSIONS

Cultural factors embodied in mutual misperceptions, attitudes, beliefs exist between CAMHS and AMHS. Working practices can exert either positive or negative effects on transition and continuity of care. Implementation of shared education and training, standardised approaches to record keeping and information transfer, supported by compatible IT resources are recommended, alongside management strategies which evaluate the achievement of outcomes related to transition and continuity of care.

'Talking a different language': an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services

BACKGROUND

Organizational culture is manifest in patterns of behaviour underpinned by beliefs, values, attitudes and assumptions, which can influence working practices. Cultural factors and working practices have been suggested to influence the transition of young people moving from child to adult mental health services. Failure to manage and integrate transitional care effectively can lead to young people losing contact with health and social care systems, resulting in adverse effects on health, well-being and potential.

METHODS

The study aim was to identify the organisational factors which facilitate or impede transition of young people from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) from the perspective of health professionals and representatives of voluntary organisations. Specific objectives were (i) to explore organizational cultures, structures, processes and resources which influence transition from child to adult mental health services; (ii) identify factors which constitute barriers and facilitators to transition and continuity of care and (iii) make recommendations for service improvements. Within an exploratory, qualitative design thirty four semi-structured interviews were conducted with health and social care professionals working in CAMHS and AMHS in four NHS Mental Health Trusts and four voluntary organizations, in England.

RESULTS

A cultural divide appears to exist between CAMHS and AMHS, characterized by different beliefs, attitudes, mutual misperceptions and a lack of understanding of different service structures. This is exacerbated by working practices relating to communication and information transfer which could impact negatively on transition, relational, informational and cross boundary continuity of care. There is also evidence of a cultural shift, with some positive approaches to collaborative working across services and agencies, involving joint posts, parallel working, shared clinics and joint meetings.

CONCLUSIONS

Cultural factors embodied in mutual misperceptions, attitudes, beliefs exist between CAMHS and AMHS. Working practices can exert either positive or negative effects on transition and continuity of care. Implementation of shared education and training, standardised approaches to record keeping and information transfer, supported by compatible IT resources are recommended, alongside management strategies which evaluate the achievement of outcomes related to transition and continuity of care.

[Paediatric features in childhood renal transplantation: quality of life, school, adherence, transfer to adult nephrologists]

The quality of life of children having undergone renal transplantation is slightly lower than in the general population, whereas it is rather better in transplanted adolescents. The parent's quality of life is often affected. School attendance is affected by the disease and school performances lower as an outcome, however the level of unemployment at adulthood remains similar to the general population. Treatment compliance is high in young children, but low in adolescents, resulting in frequent rejection episodes and reduced graft survival. Multidisciplinary patient management is essential, possibly in a patient's therapeutic education unit. Implementation of special measures is recommended to reduce the risks associated with the transition from pediatric to adult unit.

The transition of adult patients with childhood-onset chronic diseases from pediatric to adult healthcare systems: a survey of the perceptions of Japanese pediatricians and child health nurses

Background

Advances in medical science have enabled many children with chronic diseases to survive to adulthood. The transition of adult patients with childhood-onset chronic diseases from pediatric to adult healthcare systems has received attention in Europe and the United States. We conducted a questionnaire survey among 41 pediatricians at pediatric hospitals and 24 nurses specializing in adolescent care to compare the perception of transition of care from pediatric to adult healthcare services for such patients.

Findings

Three-fourths of the pediatricians and all of the nurses reported that transition programs were necessary. A higher proportion of the nurses realized the necessity of transition and had already developed such programs. Both pediatricians and nurses reported that a network covering the transition from pediatric to adult healthcare services has not been established to date.

Conclusions

It has been suggested that spreading the importance of a transition program among pediatricians and developing a pediatric-adult healthcare network would contribute to the biopsychosocial well-being of adult patients with childhood-onset chronic disease.

Inflammatory bowel disease in transition: challenges and solutions in adolescent care

The prevalence of inflammatory bowel disease (IBD) in childhood is increasing with a phenotype now established as one of complicated and extensive disease. Adolescent patients form a significant proportion of those requiring lifelong care. One of the most important steps in establishing a personal ability to effectively manage chronic disease is appropriate education, communication and a good relationship with healthcare professionals and a successful transition programme and subsequent transfer to adult care underpins this. It is vital to build trust and include parental input while transferring responsibility to the young person Although the literature confirms that the majority of paediatric gastroenterology units now have planned provision for transfer, the quality and appropriateness of these services have not been assessed or audited. This article discusses the drivers for establishing and improving transition services from both the patient's and healthcare provider's perspective. This heterogeneity of provision of healthcare for adolescents needs to be addressed and the experience of young people themselves is good evidence of this need. Barriers to optimal care need to be identified and managed and healthcare providers need to 'buy in' to establishing a flexible, patient focused achievable service for their patient population.

Parents' perception of self-advocacy of children with myositis: an anonymous online survey

BACKGROUND

Children with complex medical issues experience barriers to the transition of care from pediatric to adult providers. We sought to identify these barriers by elucidating the experiences of patients with idiopathic inflammatory muscle disorders.

METHODS

We collected anonymous survey data using an online website. Patients and their families were solicited from the US and Canada through established clinics for children with idiopathic inflammatory muscle diseases as well as with the aid of a nonprofit organization for the benefit of such individuals. The parents of 45 older children/young adults suffering from idiopathic inflammatory muscle diseases were surveyed. As a basis of comparison, we similarly collected data from the parents of 207 younger children with inflammatory muscle diseases. The survey assessed transition of care issues confronting families of children and young adults with chronic juvenile myositis.

RESULTS

Regardless of age of the patient, respondents were unlikely to have a designated health care provider assigned to aid in transition of care and were unlikely to be aware of a posted policy concerning transition of care at their pediatrician's office. Additionally, regardless of age, patients and their families were unlikely to have a written plan for moving to adult care.

CONCLUSIONS

We identified deficiencies in the health care experiences of families as pertain to knowledge, self-advocacy, policy, and vocational readiness. Moreover, as children with complex medical issues grow up, parents attribute less self-advocacy to their children's level of independence.

Child maltreatment and the transition to adult-based medical and mental health care

BACKGROUND

Child maltreatment is a public health problem with lifelong health consequences for survivors. Each year, >29 000 adolescents leave foster care via emancipation without achieving family permanency. The previous 30 years of research has revealed the significant physical and mental health consequences of child maltreatment, yet health and well-being have not been a priority for the child welfare system.

OBJECTIVES

To describe the health outcomes of maltreated children and those in foster care and barriers to transitioning these adolescents to adult systems of care.

METHODS

We reviewed the literature about pediatric and adult health outcomes for maltreated children, barriers to transition, and recent efforts to improve health and well-being for this population.

RESULTS

The health of child and adult survivors of child maltreatment is poor. Both physical and mental health problems are significant, and many maltreated children have special health care needs. Barriers to care include medical, child welfare, and social issues. Although children often have complex medical problems, they infrequently have a medical home, their complex health care needs are poorly understood by the child welfare system that is responsible for them, and they lack the family supports that most young adults require for success. Recent federal legislation requires states and local child welfare agencies to assess and improve health and well-being for foster children.

CONCLUSIONS

Few successful transition data are available for maltreated children and those in foster care, but opportunities for improvement have been highlighted by recent federal legislation.

Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study

BACKGROUND

Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS).

AIMS

As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS.

METHOD

We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced.

RESULTS

Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health.

CONCLUSIONS

For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.

Enough of the problem: a review of time for health care transition solutions for young adults with a chronic illness

AIMS AND OBJECTIVES

In this article, we critically assess the state of the science of transition care in chronic conditions using diabetes care as an exemplar and provide a case for the adoption of the principles of the Chronic Care Model in driving health care reform.

BACKGROUND

Globally, there is an increasing burden of chronic conditions including among adolescents and young adults. As a consequence adolescents are transitioning, at an increasing rate, from paediatric services into mainstream adult services, which are often ill equipped to meet their needs.

DESIGN

Integrative literature review.

METHODS

An integrative literature review method was used to summarise key issues facing adolescents with chronic illness and generate strategies for improving health care services.

CONCLUSION

Strengthening the capacity for transitioning from a service that is family focused to one with an individual orientation requires a paradigmatic shift and clear identification of roles and responsibilities in the health care system. The absence of empirically developed models of care, in a context of growing need, signals the importance of ongoing discussion, debate and research.

IMPLICATIONS FOR CLINICAL PRACTICE

There is a need for a change in philosophical orientation to promote service provision on the basis of need, rather than a model based on diagnosis and chronology. Nurses and other health professionals need to increase their awareness of issues facing adolescents with chronic conditions making the transition to adult health services.

Impact of computer-based patient education on illness-specific knowledge and renal function in adolescents after renal transplantation

Interactive CBE holds potential to increase IRK and IRB in adolescents following transplantation. An experimental design assessed the effect of CBE on IRK and renal function in adolescents after transplantation (N = 50, aged 15-20 yr). The IGr (N = 26) completed a nine-item questionnaire (9-iQ) covering IRK and IRB prior to completing CBE at three consecutive time points (T0-T2). The CGr (N = 24) received standard care. Renal function was determined by GFR 12 months before, at start of intervention, and at three, six, and 12 months after intervention (T-1; T0; T3; T4; T5). Overall IRK improved significantly over time (p < 0.0001) for IGr patients relative to CGr. Analysis of IRK demonstrated a significant increase in knowledge from T0 to T1 (p < 0.028) and from T1 to T2 (p < 0.045) in the IGr when compared to the CGr. With respect to IRB, a tendency to improve was seen (p = 0.06). The GFR gradient was stable in the IGr relative to a significant decrease in the CGr (p < 0.001). Our data suggest that interactive CBE improves IRK in adolescent renal transplant recipients. In addition, these programmes demonstrate improvements on IRB.

Nonadherence and the transition to adulthood

1. Rates of nonadherence among pediatric transplant recipients are as high as 50% to 65%, and this places adolescent transplant recipients at increased risk. 2. Adherence to immunosuppressant medications is a critical factor in the transition process as poor medication adherence is associated with an increased risk of poor long-term health outcomes. 3. Before transferring to adult-centered care, the pediatric transplant recipient should demonstrate adequate regimen knowledge and self-management skills. 4. Future research is needed to identify factors and interventions that affect long-term health outcomes in pediatric transplant recipients, including factors related to nonadherence and the successful transfer from pediatric care to adult-centered care.

Transitioning Survivors of Central Nervous System Tumors: Challenges for Patients, Families, and Health Care Providers

Survivors of central nervous system tumors (SCNST) are a growing group of cancer survivors who require risk-based, long-term health care due to the chemotherapy, surgery, and radiation they have received.Although treatment strategies are being developed to reduce morbidity and mortality, ultimately this subgroup of pediatric cancer survivors often faces moderate to severe late effects of their treatment.As a result, they will need lifelong health care that includes risk-based health care due to cancer treatment exposures as well as primary adult health care, including primary and secondary preventative care. The best way to accomplish lifelong health care for SCNST as they enter adulthood is not clearly defined. In this article, the authors plan to (1) present an overview of the complexities of health care problems that make transition challenging for SCNST; (2) review the evolving transition literature; (3) explore the barriers to successful transition; (4) discuss methods to facilitate transition; (5) describe approaches, strategies, and models for survivorship care in SCNST; (6) present issues for consideration when transitioning SCNST; and (7) provide information on transition-related resources.

Transition of children with inflammatory bowel disease: Big task, little evidence

Children with chronic long-term disorders need to move to the adult practice at some point in their life. Establishing a smooth and efficient transition process is a complicated task. Transition of medical care to adult practice is defined as the purposeful planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-oriented health care systems. This step is of the utmost importance for several reasons. There is an obvious deficiency of research in this area especially when it comes to pediatric inflammatory bowel disease (IBD). There is a considerable difference in individual practice among different centers. Also, age of transition varies among different countries and sometimes, even within the same country, transition age may vary among different provinces and districts! Interestingly, local politics and many factors other than children’s welfare often play a role in deciding the age that older children move to adult practice at. This review discusses transition of children with IBD in view of the available evidence.

Transition of adolescents with inflammatory bowel disease from pediatric to adult care: a survey of adult gastroenterologists

OBJECTIVES

Transition of patients with inflammatory bowel disease (IBD) from pediatric to adult providers requires preparation. Gastroenterologists for adult patients ("adult gastroenterologists") may have expectations of patients that are different from those of pediatric patients. We sought to explore the perspectives of adult gastroenterologists caring for adolescents and young adults with IBD, to improve preparation for transition.

MATERIALS AND METHODS

A survey sent to 1132 adult gastroenterologists caring for patients with IBD asked physicians to rank the importance of patient competencies thought necessary in successful transition to an adult practice. Providers reported which problems occurred in patients with IBD transitioning to their own practice. Adult gastroenterologists were asked about medical and developmental issues that are unique to adolescence.

RESULTS

A response rate of 34% was achieved. Adult gastroenterologists reported that young adults with IBD often demonstrated deficits in knowledge of their medical history (55%) and medication regimens (69%). In addition, 51% of adult gastroenterologists reported receiving inadequate medical history from pediatric providers. Adult providers were less concerned about the ability of patients to identify previous and current health care providers (19%), or attend office visits by themselves (15%). Knowledge of adolescent medical and developmental issues was perceived as important by adult gastroenterologists; however, only 46% felt competent addressing the developmental aspects of adolescents.

CONCLUSIONS

For successful transition, adolescents and young adults with IBD need improved education about their medical history and medications. Pediatric providers need to improve communication with the receiving physicians. In addition, adult providers may benefit from further training in adolescent issues. Formal transition checklists and programs may improve the transition of patients with IBD from pediatric to adult care.

[The adolescent to adulthood transition of persons with traumatic-brain injury: the physical-medicine point of view]

Traumatic-brain injury (TBI) is relatively frequent and can involve children and adolescents; it causes not only physical but also important neuropsychological and behavioral problems that can impair familial, social, and professional reintegration. The affected person requires long-term follow-up of medical, psychological, and social problems. The transition from childhood to adulthood, which can cause problems related to the lack of organization and training of specialized TBI medicosocial teams and structures in adult care for both the family, which is reluctant to change, and the patient, who often shows anosognosia, therefore requires organized coordination between pediatric and adult-care teams. This transition must be prepared early and in collaboration with the patient and his family. It first concerns physicians, both pediatric and adult specialists, who need to develop closer collaboration and cooperation. However, the patient should remain the main actor, because the objective is to transfer diversified healthcare, which depends on the TBI patient's individual problems. This relates to medical treatments and, more generally, the life project, which should not be disturbed by divergent practices. The main measures enabling harmonious transfer are training, establishment of specific procedures, and, most particularly, networking.

Access to care for youth with special health care needs in the transition to adulthood

PURPOSE

To describe access to care and identify factors associated with access for low-income young adults who aged out of a public program for children with special health care needs (CSHCN).

METHODS

This was a cross-sectional survey of graduates of the Title V CSHCN program in one California county. Subjects were 77 graduates (55% female) aged 21-24 years with ongoing health care needs. Measures of access to care included having the following: a regular source of care for the main health condition; all needed care since turning 21 years of age; any delayed or forgone care in the past 6 months; health insurance; and continual insurance since turning age 21. Individuals lacking any one access measure were defined as experiencing an adverse transition event.

RESULTS

Of the subjects, 24% lacked a usual source of health care, 27% had gone without some needed health care since turning 21, and 39% had delayed needed care. Although 10% of respondents were uninsured at the time of the survey; 40% had a gap in insurance coverage since turning age 21. Overall, 65% reported at least one adverse transition event affecting access to care. Factors associated with experiencing no adverse transition event were receiving Supplemental Security Income (SSI, p = .007), having received special education services (p = .003), and having been born with the main health condition (p = .013).

CONCLUSIONS

Insurance gaps and delayed care are prevalent among these low-income young adults despite ongoing health problems. Greater transition support might improve access by linking them with a usual source of care, identifying insurance options, and encouraging regular use of care.

Survey of primary care pediatricians on the transition and transfer of adolescents to adult health care

The transition and transfer from pediatrics to adult health care of youth with and without special health care needs has become a focus of professional organizations, health care insurers, national policy makers, and providers. To understand transition and transfer at a primary care practice level, all primary care pediatricians in Rhode Island were surveyed. Responses were received from 103 of 169 (60.9%) practicing pediatricians. Few responders had practice policies on transfer. Most reported that transition should begin later than recommended. Few practices communicated with adult providers at transfer. Most reported that health insurers were of little help in transfer. Many pediatric practices had young adults after age 22 and many with special needs. Responders reported adolescents left their practices by 1 of 6 methods. The survey indicates the need for further study of transition and transfer and the need for additional training and education if transfers are to be successful.

Healthcare transition in persons with intellectual disabilities: general issues, the Maastricht model, and Prader-Willi syndrome

In current healthcare, transitional healthcare is a very important and timely issue. Thanks to the major advances made in medical care and technology, many children with childhood onset diseases and/or genetic syndromes survive to adulthood. These children are at risk of not being provided with adequate healthcare as they reach adulthood. Healthcare transition is an essential part of healthcare provision, referred to as the shift from one type of healthcare to another. In Maastricht, we developed a transition/out clinic led by a medical doctor specialized in persons with intellectual disability (ID), together with a clinical geneticist. We aim to coordinate healthcare issues based on guidelines if available. Also questions concerning living, daily activities, relations, sexuality, and sterilization can be discussed. The aging process of persons with ID has been a topic of interest in recent years. Little is known about the aging process of people with specific syndromes, except for persons with Down syndrome. We present some data of a recent questionnaire study in persons with Prader-Willi syndrome. In only 50% in persons with a clinical diagnosis genetic test results could be reported. The majority of persons were obese. Diabetes mellitus, hypertension, skin problems, sleep apnea, and hormonal problems like osteoporosis and hypothyroidism were common. Psychiatric problems were frequent, especially in the persons with uniparental disomy. Osteoporosis and sleep apnoea seem to be underestimated. Further longitudinal research is necessary for a better understanding of the aging process in PWS.

What Do We Really Know About the Transition to Adult-Centered Health Care? A Focus on Cerebral Palsy and Spina Bifida

OBJECTIVES

To address the lack of synthesis regarding the factors, processes, and outcomes specific to the transition from child-centered to adult-centered health care for people with cerebral palsy (CP) and spina bifida (SB); more specifically, to identify barriers, to outline key elements, to review empirical studies, and to make clinical and research recommendations.

DATA SOURCES

We searched Medline and CINAHL databases from 1990 to 2006 using the key words: transition, health care transition, pediatric health care, adult health care, health care access, health care use, chronic illness, special health care needs, and physical disability. The resulting studies were reviewed with a specific focus on clinical transition for persons with CP and SB, and were supplemented with key information from other diagnostic groups.

STUDY SELECTION

All studies meeting the inclusion criteria were included.

DATA EXTRACTION

Each article classified according to 5 criteria: methodology, diagnostic group, country of study, age group, and sample size.

DATA SYNTHESIS

We identified 149 articles: 54 discussion, 21 case series, 28 database or register, 25 qualitative, and 34 survey articles (some included multiple methods). We identified 5 key elements that support a positive transition to adult-centered health care: preparation, flexible timing, care coordination, transition clinic visits, and interested adult-centered health care providers. There was, however, limited empirical evidence to support the impact of these elements.

CONCLUSIONS

This review summarizes key factors that must be considered to support this critical clinical transition and sets the foundation for future research. It is time to apply prospective study designs to evaluate transition interventions and determine long-term health outcomes.