A formal transition process ensures that young people, their carers and clinicians are fully aware of what is involved.
Health services working with people aged between 14–25 years who have a chronic condition, need this process to include, but not be limited to:
- transition guidelines and policies, including when last appointments are made and the local process for transition planning
- clear referral pathways for transition of young people
- available resources and support
- a youth focus for all facilities managing adolescents and young adults.
A co-design and journey mapping process with consumers, paediatric and adult clinicians and primary care is recommended when developing or reviewing local transition processes.
It is also useful to have a local transition committee to develop and review local guidelines and policies and to discuss issues that arise. The committee should include:
- clinicians involved in adolescent and young adult care
- young people and carers
- executive sponsors and senior leaders
- all relevant professionals.
This may involve expanding existing committees to include young people rather than forming a new committee. Encouraging clinicians, young people and carers to regularly talk about transition and the processes will help build this as part of routine care.
There has been no communication regarding the transition process which leads to feelings of neglect, lack of support and potential gaps in continuing healthcare. Aldo S, father of a 19-year-old*
Measures
System and service measures
- All health services who manage young people with chronic conditions aged 14–25 years to have local processes and structures that focus on the transition needs of young people with chronic conditions.
- All health facilities that work with young people to have a transition policy developed in consultation with young people.
- Audit of transition processes to be conducted yearly.
Patient and consumer measures
- Young people provide input into local transition policies and processes.
- A diverse range of young people are represented on relevant youth and transition committees.
Resources
- Transition and Trapeze Practice Guideline - Sydney Children’s Hospitals Network
- South Western Sydney LHD Paediatric to Adult Service. Phone Traxside Youth Health on (02) 4625 0880
- Safety Issues at Transitions of Care - a report on pain points relating to clinical information systems from the Australian Commission on Safety and Quality in Health Care
- Youth Friendly Checklist for Health Services - a checklist for service providers to plan how to improve health services for young people from NSW Health, based on research into young people’s access to services and the Youth Health Better Practice Framework.
- Supporting young people during transition to adult mental health services - NSW Health guideline
- Discharge Planning and Transfer of Care for Consumers of NSW Health Mental Health Services - NSW Health policy
- Transition to Adult Health Care Providers for Young People with a Chronic Health Condition - a clinical guideline from Hunter New England Local Health District
- Stages of transition - a fact sheet for consumers
- Co-design toolkit
References
- Chaudhry SR, Keaton M, Nasr SZ. Evaluation of a cystic fibrosis transition program from pediatric to adult care. Pediatr Pulmonol. 2013 Jul;48(7):658-65. DOI: 10.1002/ppul.22647
- Cramm JM, Strating MM, Sonneveld HM, et al. The Longitudinal Relationship Between Satisfaction with Transitional Care and Social and Emotional Quality of Life Among Chronically Ill Adolescents. Appl Res Qual Life. 2013;8(4):481-91. DOI: 10.1007/s11482-012-9209-3
- Foster HE, Minden K, Clemente D, et al. EULAR/PReS standards and recommendations for the transitional care of young people with juvenile-onset rheumatic diseases. Ann Rheum Dis. 2017;76(4):639-46. DOI: 10.1136/annrheumdis-2016-210112
- Kime N, Bagnall A, Day R. Systematic review of transition models for young people with long-term conditions: A report for NHS Diabetes. Project Report. 2013. Available from: https://eprints.leedsbeckett.ac.uk/id/eprint/606/
- Moceri P, Goossens E, Hascoet S, et al. From adolescents to adults with congenital heart disease: the role of transition. Eur J Pediatr. 2015;174(7):847-54. DOI: 10.1007/s00431-015-2557-x
- Suris JC, Akre C. Key elements for, and indicators of, a successful transition: an international Delphi study. J Adolesc Health. 2015 Jun;56(6):612-8. DOI: 10.1016/j.jadohealth.2015.02.007
- Tanner AE, Philbin MM, DuVal A, et al. Transitioning HIV-Positive Adolescents to Adult Care: Lessons Learned From Twelve Adolescent Medicine Clinics. J Pediatr Nurs. 2016;31(5):537-43. DOI: 10.1016/j.pedn.2016.04.002
- Viner R. Barriers and good practice in transition from paediatric to adult care. J R Soc Med. 2001;94 Suppl 40(Suppl 40):2-4.
* Name has been changed to protect privacy