A Qualitative Descriptive Study Exploring the Systemic Challenges of Caring for Children With Medical Complexity at Home

INTRODUCTION

The purpose of this study is to explore challenges within the home care system encountered by parental caregivers of children with medical complexity in Massachusetts.

METHOD

A qualitative descriptive study was completed with 11 parental caregivers interviewed.

RESULTS

Using conventional content analysis of transcripts, three themes emerged: (1) lack of discharge preparedness causes emotional distress, (2) care becomes increasingly complex creating new unanticipated challenges, and (3) psychological toll of parents assuming provider role.

DISCUSSION

Navigating a variety of complex systemic challenges with minimal preparation or support contributes to an overall feeling of parental caregiver burnout. Additionally, mental health supports for parental caregivers are lacking, further exacerbating the negative impact of these challenges. Future work should focus on research, advocacy, and system reform that ensures parental caregivers receive necessary supports to care for children within a sustainable and supportive home care model. Nurses across the profession are in unique position to facilitate this change.

Surviving transition: A qualitative case study on how families adapt as their youth with medical complexity transitions from child to adult systems of care

Background

A growing population of youth with medical complexity (YMC) are entering adult health care, education, and social systems in which their needs have been largely neglected. To better support YMC and their families, an understanding of how they manage the challenges of transitioning to adult services is needed. The aim of this study was to examine how families of YMC adapt to challenges and opportunities posed by the youth's transition to adulthood and transfer to adult services.

Methods

In partnership with two parent co-researchers and underpinned by complex adaptive systems and the Life Course Health Development framework, a qualitative explanatory case study was conducted. Seventeen participants from 11 families of YMC (aged 16-30) living in Ontario were recruited. Data from 21 semi-structured interviews were analyzed using reflexive thematic analysis and further refined through theory-driven analysis. Supplementary documents shared by participants were analyzed using directed content analysis.

Findings

Three overarching themes were generated. "Imagining, pursuing, and building a good future" describes families' priorities and visions for the youth's life as an adult. "Perils and obstacles of an imposed transition" examines challenges that families face in their pursuit of a good future. Lastly, "surviving the transition" describes how families are forced to advocate, make sacrifices, and persist in their efforts to adapt to transition.

Conclusions

Pediatric providers should offer anticipatory guidance, partner with families in advocacy, and provide psychological support during transition. Education for adult and primary care providers should focus on developing professional competencies in the safe care of YMC, building capacity through clinical exposure, and creating culturally safe environments. Most importantly, YMC and their families need a model of care that can provide integrated, holistic, multidisciplinary care management across the lifespan.

Pediatric to adult primary care transition for medically complex youth: A tale of learning from challenges experienced implementing a pilot project during COVID-19

Purpose

The aim of our article is to describe our learning based on challenges encountered implementing two related pediatric to adult primary care transition pilots for medically complex adolescents and young adults as part of the Children with Medical Complexity Collaborative for Improvement and Innovation Network.

Design

We undertook two sequential pilot projects. The first focused on supporting the transfer stage for an older group of medically complex young adults to facilitate their establishment with an adult primary care provider. Based on our learning from barriers encountered, and setting constraints due to COVID-19, we developed and implemented a second project to engage pediatric primary care providers in initiating and documenting transition preparation discussions for a younger group of medically complex youth. A multi-disciplinary Implementation Team guided each phase's implementation.

Results

We did not achieve our objective in the first pilot, partly due to provider reluctance. Providers perceived the patient was not ready, reported that the patient was experiencing active health problems, or wanted to keep the patient on their panel. We partially achieved the second pilot's objective; three-quarters of identified patients completed their appointments, and electronic health record documentation suggests that providers initiated transition discussions with more than half of those patients.

Conclusions

Pediatric primary care has an important role in supporting health care transition for medically complex youth. Our findings suggest that pediatric primary care providers require time, connection to adult PCPs, and educational support to realize this role.

Practice implications

To provide comprehensive transition services for medically complex patients, pediatric primary care will need to develop relationships with adult primary care providers, make available training about transition preparation for its providers, and support patients and families in locating adult primary care providers who are accepting new patients.

Improving the transition from paediatric to adult healthcare: a scoping review on the recommendations of young adults with lived experience

OBJECTIVE

The goal of this review was to identify recommendations within the literature on how to improve the transition from paediatric to adult healthcare from the perspective of young adults (YAs) living with chronic conditions who have gone through the process.

DESIGN

This review was conducted in accordance with JBI methodology for scoping reviews.

SEARCH STRATEGY

We searched MEDLINE (Ovid), CINAHL (EBSCO), PsycINFO (EBSCO) and EMBASE (Elsevier) databases, and conducted a grey literature search for relevant material. The databases were searched in December 2019, and re-searched June 2020 and September 2020, while the grey literature was searched in April 2020. This scoping review focused on the recommendations of YAs with chronic conditions who have transitioned from paediatric to adult healthcare, in any setting (eg, hospital, clinic or community), and across all sectors (eg, health, education and social services).

RESULTS

Eighteen studies met inclusion criteria for this review. These studies included YAs with 14 different chronic conditions, receiving primary health services in North America (67%) and Europe (33%). YAs' recommendations for improving the transition from paediatric to adult healthcare (n=number of studies reported) included: improving continuity of care (n=12); facilitating patient-centred care (n=9); building strong support networks (n=11) and implementing transition education preparedness training (n=7).

CONCLUSION

Review findings can benefit service delivery by addressing important barriers to health, education, and social services for youth transitioning to adult healthcare.

A call for action: Recommendations to improve transition to adult care for youth with complex health care needs

Youth with complex health care needs, defined as those requiring specialized health care and services for physical, developmental, and/or mental health conditions, are often cared for by paediatricians and paediatric specialists. In Canada, the age at which provincial/territorial funders mandate the transfer of paediatric care to adult services varies, ranging between 16 and 19 years. The current configuration of distinct paediatric and adult care service boundaries is fragmentary, raising barriers to continuity of care during an already vulnerable developmental period. For youth, the lack of care integration across sectors can negatively impact health engagement and jeopardize health outcomes into adulthood. To address these barriers and improve transition outcomes, paediatric and adult care providers, as well as family physicians and other community partners, must collaborate in meaningful ways to develop system-based strategies that streamline and safeguard care for youth transitioning to adult services across tertiary, community, and primary care settings. Flexible age cut-offs for transfer to adult care are recommended, along with considering each youth's developmental stage and capacity as well as patient and family needs and circumstances. Specialized training and education in transitional care issues are needed to build capacity and ensure that health care providers across diverse disciplines and settings are better equipped to accept and care for young people with complex health care needs.

Appel à l'action : des recommandations pour améliorer la transition des jeunes ayant des besoins de santé complexes vers les soins aux adultes

Les jeunes qui ont des besoins de santé complexes, définis comme ceux qui nécessitent des soins et services spécialisés en raison d'affections physiques, développementales ou mentales, sont souvent traités par des pédiatres et autres spécialistes en pédiatrie. Au Canada, l'âge auquel les bailleurs de fonds provinciaux et territoriaux exigent le transfert des soins pédiatriques aux soins pour adultes varie entre 16 et 19 ans. La délimitation actuelle entre les services de santé pédiatriques et aux adultes est fragmentaire, ce qui entrave la continuité des soins pendant une période déjà vulnérable du développement. Le peu d'intégration des soins entre les domaines peut nuire à l'engagement des jeunes en matière de santé et compromettre leur santé à l'âge adulte. Pour renverser ces obstacles et améliorer les résultats de la transition, les dispensateurs de soins pédiatriques et de soins aux adultes, de même que les médecins de famille et d'autres partenaires communautaires, doivent collaborer de manière satisfaisante à l'élaboration de stratégies systémiques qui rationalisent et préservent les soins aux jeunes en transition vers des soins aux adultes en milieu tertiaire, communautaire et primaire. Il est recommandé de privilégier des limites d'âge flexibles pour effectuer cette transition vers les soins aux adultes et de tenir compte de la phase de développement et de l'aptitude de chaque jeune, ainsi que des besoins et de la situation de chaque patient et de chaque famille. Une formation et un enseignement spécialisés sur les enjeux liés aux soins de transition s'imposent pour renforcer les capacités et s'assurer que les professionnels de la santé des diverses disciplines et des divers milieux soient mieux outillés pour accepter et traiter les jeunes qui ont des besoins de santé complexes.

The role of family adaptation in the transition to adulthood for youth with medical complexity: a qualitative case study protocol

Background

For youth with medical complexity and their families, the transition to adulthood is a stressful and disruptive period that is further complicated by the transfer from relatively integrated and familiar pediatric services to more fragmented and unfamiliar adult services. Previous studies report that families feel abandoned, overwhelmed, and unsupported during transition. In order to provide better support to families, we need to understand how families currently manage transition, what supports they need most, and how key factors influence their experiences. The aim of this study is to understand how families of youth with medical complexity adapt to the youth’s transition to adulthood and transfer to adult health care, social, and education services, and to explain how contextual factors interact to influence this process.

Methods

Informed by the Life Course Health Development framework, this study will use a qualitative explanatory case study design. The sample will include 10–15 families (1–3 participants per family) of youth with medical complexity (aged 16–30 years) who have lived experience with the youth’s transition to adulthood and transfer to adult services. Data sources will include semi-structured interviews and resources participants identified as supporting the youth’s transition. Reflexive thematic analysis will be used to analyze interview data; directed content analysis will be used for documentary evidence.

Discussion

While previous studies report that families experience significant challenges and emotional toll during transition, it is not known how they adapt to these challenges. Through this study, we will identify what is currently working for families, what they continue to struggle with, and what their most urgent needs are in relation to transition. The anticipated findings will inform both practice solutions and policy changes to address the needs of these families during transition. This study will contribute to the evidence base needed to develop novel solutions and advance policies that will meaningfully support successful transitions for families of youth with medical complexity.

Transition to adult dental care from a pediatric hospital dental home for patients with special health care needs

AIMS

This study describes patients with complex Special Health Care Needs (SHCN) transitioning from a pediatric hospital clinic dental home to adult care and evaluates effectiveness of transition practices.

METHODS AND RESULTS

Demographics, medical/behavioral complexity, and documentation of transition processes were collected for patients graduated from the service in 2018/2019. An invitation to complete a survey assessing transition was sent to patients/guardians ≥ 14 months after the final visit. Seventy-nine patients graduated and 94% required accommodation for SHCN: 47% medical, 42% medical + behavioral, and 5% behavioral only. Of 63 eligible patients/guardians, 29 completed surveys. While 90% of surveyed patients had established some/all adult medical care, only 41% completed a dental visit, and less than 28% established a dental home. Medical/behavioral complexity, payer, and time since graduation did not impact having a visit.

CONCLUSIONS

This study found ineffectiveness of departmental protocol for transition to adult dental homes for patients with SHCN. Developing an optimal transition process is complex and will require collaboration of all stakeholders. Introducing transition in early teen years, tracking progress at subsequent visits, assessing patient readiness, summarizing history for receiving providers, and verifying transition are elements of medical transition programs that should be included in dental transitions.

Transition to adult care for youth with medical complexity: Assessing needs and setting priorities for a health care improvement initiative

BACKGROUND

Technological advances have led to more youth with medical complexity (YMC) who are living into adulthood and being transferred from pediatric to adult care. The transition to adult care is a complex and challenging process, partly due to differences in how pediatric and adult systems deliver health care. YMC and their families need support from their health care providers to ease this transition. To identify how to better support transitioning YMC, a needs assessment was conducted to examine the current state of transitional support for youth and families cared for by a pediatric Complex Care Program.

AIMS

The aims of this needs assessment were to understand the transition practices of pediatric Complex Care Programs, explore transition-related needs of YMC and their families, and identify priorities for future quality improvement.

METHODS

This project involved three components: a literature review, a benchmarking survey of pediatric Complex Care Programs in Ontario, and key informant interviews.

FINDINGS

The benchmarking survey identified transition planning and transfer of care as areas of strength in the Complex Care Program, while transition readiness and transfer completion provided opportunities for improvement. Stakeholder collaboration, an early start, and knowledgeable providers facilitated a successful transition. Barriers included lack of time, poor access to adult services and resources, higher medical complexity, and inadequate support for adult health care providers.

CONCLUSIONS

Recommendations for improving transitional care for YMC are provided, along with resources, tools, and considerations for implementation.