Current status of transition preparation among youth with special needs in the United States

Management considerations for the adult with congenital adrenal hyperplasia

The congenital adrenal hyperplasias (CAH) are a group of genetic defects in cortisol biosynthesis, most commonly steroid 21-hydroxylase deficiency (21OHD). With the advent of cortisone therapy in the 1960s and newborn screening in the 1990s, most children with 21OHD now reach adulthood. The needs and concerns of adults with 21OHD overlap with those of children, but the focus and approach shift as these patients reach adulthood. Cohort studies suggest that adults with 21OHD experience significant health concerns such as infertility, obesity, short stature, neoplasia, and bone loss, as well as reduced quality of life. Nevertheless, the spectrum of health status and disease severity is broad, but only some of the reasons for these disparities are known. This review will summarize the current state of knowledge and suggested approaches to management adults with classic 21OHD, plus a few major considerations for adults with nonclassic 21OHD.

Predictors of timing of transfer from pediatric- to adult-focused primary care

IMPORTANCE

A timely, well-coordinated transfer from pediatric- to adult-focused primary care is an important component of high-quality health care, especially for youths with chronic health conditions. Current recommendations suggest that primary-care transfers for youths occur between 18 and 21 years of age. However, the current epidemiology of transfer timing is unknown.

OBJECTIVE

To examine the timing of transfer to adult-focused primary care providers (PCPs), the time between last pediatric-focused and first adult-focused PCP visits, and the predictors of transfer timing.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of patients insured by Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan. Our sample included 60 233 adolescents who were continuously enrolled in HPHC from 16 to at least 18 years of age between January 2000 and December 2012. Pediatric-focused PCPs were identified by the following provider specialty types, but no others: pediatrics, adolescent medicine, or pediatric nurse practitioner. Adult-focused PCPs were identified by having any provider type that sees adult patients. Providers with any specialty provider designation (eg, gastroenterology or gynecology) were not considered PCPs.

MAIN OUTCOMES AND MEASURES

We used multivariable Cox proportional hazards regression to model age at first adult-focused PCP visit and time from the last pediatric-focused to the first adult-focused PCP visit (gap) for any type of office visit and for those that were preventive visits.

RESULTS

Younger age at transfer was observed for female youths (hazard ratio [HR], 1.32 [95% CI, 1.29-1.36]) who had complex (HR, 1.06 [95% CI, 1.01-1.11]) or noncomplex (HR, 1.08 [95% CI, 1.05-1.12]) chronic conditions compared with those who had no chronic conditions. Transfer occurred at older ages for youths who lived in lower-income neighborhoods compared with those who lived in higher-income neighborhoods (HR, 0.89 [95% CI, 0.83-0.95]). The gap between last pediatric-focused to first adult-focused PCP visit was shorter for female youths than male youths (HR, 1.57 [95% CI, 1.53-1.61]) and youths with complex (HR, 1.35 [95% CI, 1.28-1.41]) or noncomplex (HR, 1.24 [95% CI, 1.20-1.28]) chronic conditions. The gap was longer for youths living in lower-income neighborhoods than for those living in higher-income neighborhoods (HR, 0.80 [95% CI, 0.75-0.85]). Multivariable models showed an adjusted median age at transfer of 21.8 years for office visits and 23.1 years for preventive visits and an adjusted median gap length of 20.5 months for office visits and 41.6 months for preventive visits.

CONCLUSIONS AND RELEVANCE

Most youths are transferring care later than recommended and with gaps of more than a year. While youths with chronic conditions have shorter gaps, they may need even shorter transfer intervals to ensure continuous access to care. More work is needed to determine whether youths are experiencing clinically important lapses in care or other negative health effects due to the delayed timing of transfer.

Key elements for, and indicators of, a successful transition: an international Delphi study

PURPOSE

The purpose of this study was to reach an international consensus to determine what key elements should be part of a transition program and what indicators could be used to assess its success.

METHODS

For this purpose, a Delphi study including an international panel of 37 experts was carried out. The study consisted of three rounds, with response rates ranging from 86.5% to 95%. At each round, experts were asked to assess key elements (defined as the most important elements for the task) and indicators (defined as quantifiable characteristics). At each round, panelists were contacted via e-mail explaining them the tasks to be done and giving them the Web link where to complete the questionnaire. At Round 3, each key element and indicator was assessed as essential, very important, important, accessory, or unnecessary. A 70% agreement was used as cutoff.

RESULTS

At Round 3, more than 70% of panelists agreed on six key elements being essential, with one of them (Assuring a good coordination between pediatric and adult professionals) reaching an almost complete consensus (97%). Additionally, 11 more obtained more than 70% agreement when combined with the Very important category. Among indicators, only one (Patient not lost to follow-up) was considered almost unanimously (91%) as essential by the panelists and seven others also reached consensus when the Very important category was included.

CONCLUSIONS

Using these results as a framework to develop guidelines at local, national, and international levels would allow better assessing and comparing transition programs.

Quantitative evaluation of a pediatric rheumatology transition program

BACKGROUND

Transition from pediatric to adult care can be a challenging process which leaves young people vulnerable to interruptions of care and worsening disease status. Efforts to improve transition processes and outcomes have included development of individualized transition plans, creation of transition clinics, and utilization of transition coordinators. Few interventions have assessed transition outcomes quantitatively.

METHODS

We assessed transition outcome and satisfaction of a social worker-centered transition program in a pediatric rheumatology clinic. The social worker met with patients who were 16 years or older and their families, provided transition education materials, assisted patients in developing an individualized transition plan, assisted in making appointments with an adult rheumatologist at time of transfer of care, and followed up with patients to assess transition outcomes. Patients were contacted 6-8 months after initial appointment with the adult rheumatologist to assess whether they remained in the care of the adult provider. Participants then completed a questionnaire to rate their satisfaction with the transition program.

RESULTS

210 adolescents and young adults participated in the transition program. Twenty-six similarly aged patients were eligible for transition services but did not participate in the program and were used as controls. Of the patients who participated in the program, 42% were considered to have transitioned successfully to adult care compared to 23% of controls (p-value = 0.002) of all patients. In the survey of satisfaction, 81% of participants said that they were satisfied with the transition process.

CONCLUSIONS

This study shows that a social worker transition coordinator can significantly improve the rate of pediatric rheumatology patients who successfully transition to adult care. Furthermore, patients are largely satisfied with this process.

The Emerging Adult with Inflammatory Bowel Disease: Challenges and Recommendations for the Adult Gastroenterologist

Incidence of pediatric inflammatory bowel disease (IBD) is rising. Adult gastroenterologists are seeing increasing numbers of young adults with IBD, a subpopulation with unique needs and challenges that can impair their readiness to thrive in an adult healthcare system. Most adult gastroenterologists might not have the training or resources to address these needs. “Emerging adulthood” is a useful developmental lens through which this group can be studied. With complex disease phenotype and specific concerns of medication side effects and reproductive health, compounded by challenges of geographical and social flux and lack of adequate health insurance, emerging adults with IBD (EAI) are at risk of disrupted care with lack of continuity. Lessons learned from structured healthcare transition process from pediatric to adult services can be applied towards challenges in ongoing care of this population in the adult healthcare system. This paper provides an overview of the challenges in caring for the post transition EAI from the perspective of adult gastroenterologists and offers a checklist of provider and patient skills that enable effective care. This paper discusses the system-based challenges in care provision and search for meaningful patient-oriented outcomes and presents a conceptual model of determinants of continuity of care in this unique population.

Federal policy supporting improvements in transitioning from pediatric to adult surgery services

For children with complex medical conditions that require ongoing surgical intervention, planning for the transition from pediatric to adult surgical care is essential. Services that support healthcare transition from specialty pediatric practices into adult practices are often inadequate, and the healthcare policy process has been slow to respond to the call to action by both professional and patient organizations. However, The Patient Protection and Affordable Care Act of 2010 (PPACA), arguably the most significant healthcare reform legislation since the enactment of Medicaid and Medicare in the mid-1960s, includes several provisions with direct influence on access to care and quality for adolescents transitioning to adult surgical care. We present a brief background on the rationale for improving surgical transition plans, the challenges of enacting the plans, and the relevance of PPACA in shaping health policy change around transition to adult services.

A qualitative study on the experiences of young adults with eating disorders transferring from pediatric to adult care

The study's objective was to identify systemic facilitators and barriers of transferring young adults (ages 17-21) with eating disorders from pediatric to adult health and mental health services. Qualitative interviews were conducted and three themes emerged: (a) difficulties navigating care during the transfer period; (b) challenges achieving and maintaining recovery due to systemic barriers after the transfer of care;and (c) recommendations for facilitating the transfer between systems of care. From the perspective of young adults with eating disorders our study shows that the transition to adult care services may be improved with increased coordination, communication, and collaborative partnerships between pediatric and adult providers.

Young adults' experiences and satisfaction with the transfer of care

PURPOSE

Transition of care of adolescents with chronic conditions is a critical area for clinicians. Patient-reported outcomes may provide important information on the quality of services. This cohort study examines young adults' experiences and satisfaction with the transfer to adult care and explores associations with patient characteristics.

METHODS

Follow-up of 518 young adults (18-25 years) with various chronic conditions who completed a Web-based survey in 2006 (response rate, 52%). Outcome measures were the 18-item On Your Own Feet Transfer Experiences Scale (α = .93) and satisfaction with the transfer process (visual analog scale). Associations with demographic and health care-related variables, health-related quality of life, and self-management were explored with stepwise multivariate modeling, using past (2006-T0) and current (2012-T1) variables.

RESULTS

Of the respondents, 315 (65%) had transferred, while 10% was still in pediatric care and 25% was not in treatment anymore. Twenty percent rated their transfer as unsatisfactory, 50% felt prepared at the time of transfer, and 24% had met their adult-centered provider in advance. Men were more positive about their experiences and rated satisfaction higher than did women. Patient-centeredness of the adult health-care provider was the most important determinant for experiences (β = .29). Higher self-efficacy at T1 was associated with more positive experiences but not with higher satisfaction. The latter was higher for those transferred within the same hospital (β = .28).

CONCLUSIONS

The On Your Own Feet Transfer Experiences Scale is a useful instrument to measure transfer experiences. The importance young adults attach to good relations with their new provider stresses the necessity of early involvement of and good collaboration with adult care.

Transition care for children with special health care needs

BACKGROUND

Approximately 750,000 children in the United States with special health care needs will transition from pediatric to adult care annually. Fewer than half receive adequate transition care.

METHODS

We had conversations with key informants representing clinicians who provide transition care, pediatric and adult providers of services for individuals with special health care needs, policy experts, and researchers; searched online sources for information about currently available programs and resources; and conducted a literature search to identify research on the effectiveness of transition programs.

RESULTS

We identified 25 studies evaluating transition care programs. Most (n = 8) were conducted in populations with diabetes, with a smaller literature (n = 5) on transplant patients. We identified an additional 12 studies on a range of conditions, with no more than 2 studies on the same condition. Common components of care included use of a transition coordinator, a special clinic for young adults in transition, and provision of educational materials.

CONCLUSIONS

The issue of how to provide transition care for children with special health care needs warrants further attention. Research needs are wide ranging, including both substantive and methodologic concerns. Although there is widespread agreement on the need for adequate transition programs, there is no accepted way to measure transition success. It will be essential to establish consistent goals to build an adequate body of literature to affect practice.

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.

From pediatric to adult care: strategic evaluation of a transition program for patients with osteogenesis imperfecta

Background

Achieving a successful transition from pediatric to adult care for young adults with special needs, especially rare genetic diseases such as osteogenesis imperfecta (OI), is a prominent issue in healthcare research. This transition represents a challenge for patients with OI, their families, clinicians and healthcare managers because of the complex nature of the process and the lack of evaluation of existing transition programs. We evaluated a transition program for adolescents and young adults with OI from a pediatric orthopedic hospital to adult care.

Methods

Data were collected by interview, observation, and document review from April 2013 to October 2013. Participants included six patients with OI, four parents, and 15 staff, including administrators, coordinators, social workers, nurses, pediatricians, surgeons, occupational therapists and physiotherapists. A SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis was performed.

Results

The strengths of the transition program included a solid theoretical approach based on a partnership with parents, and a comprehensive transition model based on fostering independent living and professional integration. The program’s main weaknesses were the successive organizational changes and discontinuation of certain transition activities, and the potential conflict between the transition program and participation in research protocols. Further opportunities include the implementation of a multi-site transition model with cross-site personnel and user evaluations, with the inclusion of second-generation patients. Dissatisfaction reported by some care-team members at the adult care hospital could threaten collaboration among institutions involved in the transition process, whereas dissatisfaction of some former patients may reduce their perceptions of quality of care received during the transition.

Conclusions

This study confirmed that a “one-size-fits-all” transition model for patients with OI would be inappropriate across, or even within institutions. Opportunities should be seized to create tailored, theoretically-sound transition programs that reflect patient preferences, especially those of young adults with complex and chronic health conditions. Alignment with other organizational activities should be considered, and ongoing evaluation of transition programming may be required. This SWOT analysis and utilization-focused evaluation has led to a comprehensive new project to improve the transition program for patients with OI and other conditions requiring special follow-up.

Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units

PURPOSE

The purpose of the study is to compare demographics, intensive care unit (ICU) admission characteristics, and ICU outcomes among adults with childhood-onset chronic conditions (COCCs) admitted to US pediatric and adult ICUs.

MATERIALS AND METHODS

Retrospective cross-sectional analyses of 6088 adults aged 19 to 40 years admitted in 2008 to 70 pediatric ICUs that participated in the Virtual Pediatric Intensive Care Unit Performance Systems and 50 adult ICUs that participated in Project IMPACT.

RESULTS

Childhood-onset chronic conditions were present in 53% of young adults admitted to pediatric units, compared with 9% of those in adult units. The most common COCC in both groups were congenital cardiac abnormalities, cerebral palsy, and chromosomal abnormalities. Adults with COCC admitted to pediatric units were significantly more likely to be younger, have lower functional status, and be nontrauma patients than those in adult units. The median ICU length of stay was 2 days, and the intensive care unit mortality rate was 5% for all COCC patients with no statistical difference between pediatric or adult units.

CONCLUSIONS

There are marked differences in characteristics between young adults with COCC admitted to pediatric ICUs and adult ICUs. Barriers to accommodating these young adults may be reasons why many such adults have not transitioned from pediatric to adult critical care.

Ready, set, stop: mismatch between self-care beliefs, transition readiness skills, and transition planning among adolescents, young adults, and parents

Health care transition (HCT) from pediatric to adult-focused systems is a key milestone for youth. Developing self-care skills and HCT planning are key elements. In a survey at 4 pediatric specialty clinics to 79 youth aged 16 to 25 years and 52 parents, skill-based HCT readiness was assessed using the Transition Readiness Assessment Questionnaire (TRAQ). Multivariable logistic regression evaluated the association between TRAQ scores and self-care beliefs. In all, 70% of youth and 67% of parents believed that they/their child could manage their care. Only 38% of youth and 53% of parents reported thinking about HCT; only 18% of youth and 27% of parents reported having a HCT plan. Youth with higher TRAQ scores were more likely to believe they could manage their care, controlling for age and gender (adjusted odds ratio = 4.0, 95% confidence interval = 1.7-9.5). Transition readiness skills are associated with self-care beliefs. However, a mismatch exists between high reported self-care beliefs and low levels of transition planning.

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.

The continuum of care for individuals with lifelong disabilities: role of the physical therapist

Many individuals with lifelong disabilities (LLDs) of childhood onset are living longer, participating in adult roles, and seeking comprehensive health care services, including physical therapy, with greater frequency than in the past. Individuals with LLDs have the same goals of health and wellness as those without disabilities. Aging with a chronic LLD is not yet well understood; however, impairments such as pain, fatigue, and osteoporosis often present earlier than in adults who are aging typically. People with LLDs, especially those living with developmental disabilities such as cerebral palsy, myelomeningocele, Down syndrome, and intellectual disabilities, frequently have complex and multiple body system impairments and functional limitations that can: (1) be the cause of numerous and varied secondary conditions, (2) limit overall earning power, (3) diminish insurance coverage, and (4) create unique challenges for accessing health care. Collaboration between adult and pediatric practitioners is encouraged to facilitate smooth transitions to health practitioners, including physical therapists. A collaborative client-centered emphasis to support the transition to adult-oriented facilities and promote strategies to increase accessibility should become standard parts of examination, goal setting, and intervention. This perspective article identifies barriers individuals with selected LLDs experience in accessing health care, including physical therapy. Strategies are suggested, including establishment of niche practices, physical accessibility improvement, and inclusion of more specific curriculum content in professional (entry-level) doctorate physical therapy schools.

Use of antihypertensive medications and diagnostic tests among privately insured adolescents and young adults with primary versus secondary hypertension

PURPOSE

To compare the use of antihypertensive medications and diagnostic tests among adolescents and young adults with primary versus secondary hypertension.

METHODS

We conducted retrospective cohort analysis of claims data for adolescents and young adults (12-21 years of age) with ≥3 years of insurance coverage (≥11 months/year) in a large private managed care plan during 2003-2009 with diagnosis of primary hypertension or secondary hypertension. We examined their use of antihypertensive medications and identified demographic characteristics and the presence of obesity-related comorbidities. For the subset receiving antihypertensive medications, we examined their diagnostic test use (echocardiograms, renal ultrasounds, and electrocardiograms).

RESULTS

The study sample included 1,232 adolescents and young adults; 84% had primary hypertension and 16% had secondary hypertension. The overall prevalence rate of hypertension was 2.6%. One quarter (28%) with primary hypertension had one or more antihypertensive medications, whereas 65% with secondary hypertension had one or more antihypertensive medications. Leading prescribers of antihypertensives for subjects with primary hypertension were primary care physicians (80%), whereas antihypertensive medications were equally prescribed by primary care physicians (43%) and sub-specialists (37%) for subjects with secondary hypertension.

CONCLUSIONS

The predominant hypertension diagnosis among adolescents and young adults is primary hypertension. Antihypertensive medication use was higher among those with secondary hypertension compared with those with primary hypertension. Further study is needed to determine treatment effectiveness and patient outcomes associated with differential treatment patterns used for adolescents and young adults with primary versus secondary hypertension.

The Transition Readiness Assessment Questionnaire (TRAQ): its factor structure, reliability, and validity

OBJECTIVE

National consensus statements recommend that providers regularly assess the transition readiness skills of adolescent and young adults (AYA). In 2010 we developed a 29-item version of Transition Readiness Assessment Questionnaire (TRAQ). We reevaluated item performance and factor structure, and reassessed the TRAQ's reliability and validity.

METHODS

We surveyed youth from 3 academic clinics in Jacksonville, Florida; Chapel Hill, North Carolina; and Boston, Massachusetts. Participants were AYA with special health care needs aged 14 to 21 years. From a convenience sample of 306 patients, we conducted item reduction strategies and exploratory factor analysis (EFA). On a second convenience sample of 221 patients, we conducted confirmatory factor analysis (CFA). Internal reliability was assessed by Cronbach's alpha and criterion validity. Analyses were conducted by the Wilcoxon rank sum test and mixed linear models.

RESULTS

The item reduction and EFA resulted in a 20-item scale with 5 identified subscales. The CFA conducted on a second sample provided a good fit to the data. The overall scale has high reliability overall (Cronbach's alpha = .94) and good reliability for 4 of the 5 subscales (Cronbach's alpha ranging from .90 to .77 in the pooled sample). Each of the 5 subscale scores were significantly higher for adolescents aged 18 years and older versus those younger than 18 (P < .0001) in both univariate and multivariate analyses.

CONCLUSIONS

The 20-item, 5-factor structure for the TRAQ is supported by EFA and CFA on independent samples and has good internal reliability and criterion validity. Additional work is needed to expand or revise the TRAQ subscales and test their predictive validity.

Assessing patient experiences in the pediatric patient-centered medical home: a comparison of two instruments

The Patient-Centered Medical Home (PCMH) is a model of care that has been promoted as a way to transform a broken primary care system in the US. However, in order to convince more practices to make the transformation and to properly reimburse practices who are PCMHs, valid and reliable data are needed. Data that capture patient experiences in a PCMH is valuable, but which instrument should be used remains unclear. Our study aims to compare the validity and reliability of two national PCMH instruments. Telephone surveys were conducted with children who receive care from 20 pediatric practices across Florida (n = 990). All of the children are eligible for Medicaid or the Children's Health Insurance Program. Analyses were conducted to compare the Consumer Assessment of Health Plan Survey-Patient-Centered Medical Home (CAHPS-PCMH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) medical home domain. Respondents were mainly White non-Hispanic, female, under 35 years old, and from a two-parent household. The NS-CSHCN outperformed the CAHPS-PCMH in regard to scale reliability (Cronbach's alpha coefficients all ≥0.81 vs. 0.56-0.85, respectively). In regard to item-domain convergence and discriminant validity the CAHPS-PCMH fared better than the NS-CSHCN (range of convergence 0.66-0.93 vs. 0.32-1.00). The CAHPS-PCMH did not correspond to the scale structure in construct validity testing. Neither instrument performed well in the known-groups validity tests. No clear best instrument was determined. Further revision and calibration may be needed to accurately assess patient experiences in the PCMH.

Pediatric provider’s perspectives on the transition to adult health care for youth with autism spectrum disorder: Current strategies and promising new directions

Few youth with autism spectrum disorder (ASD) nationally report receiving services to help them transition from the pediatric health care system to the adult health care system. For example, only one-fifth (21.1%) of youth with ASD receive any transition planning services. To better understand why the transition from pediatric to adult health care is so difficult, we interviewed pediatric health care providers with extensive experience serving youth with ASD. We gathered information about the strategies and interventions they use to transition their patients with ASD to an adult provider. Five interventions or strategies are currently being used. These include providing families with written medical summaries to give to adult providers, compiling lists of available adult providers or community resources, coordinating care and communication between individual pediatric and adult providers, making transition-specific appointments, and using checklists to track transition progress. Other interventions or strategies were identified as needed but not currently in practice, and these focused on education and training. For example, informational workshops were suggested to train families and youth about transition. Training adult providers and medical students was also seen as important. Several respondents additionally identified the need for a transition center where all services could be coordinated in one place. With large numbers of youth with ASD becoming young adults, it seems that pediatric practices might want to consider some of the activities described here. Some of these activities, such as family educational seminars and written medical summaries, are likely relatively easy for a practice to implement.

Transition of management in adolescents with IBD

Transfer of care is when a patient and his or her medical records move from one provider to another at a distinct point in time. By contrast, transition of care is a gradual process of change in knowledge, attitudes and behaviour through which the adolescent can learn to assume personal responsibility for his or her health care. IBD is a prevalent disorder, often diagnosed during childhood. Because mortality of this condition is fortunately low, children diagnosed with IBD will, at some point, transition from a paediatric to adult health-care model. Paediatric and adult health-care paradigms, including IBD-specific care, are different in a number of key areas and it is becoming increasingly apparent that young adults with chronic illness often face challenging transitions, resulting in compromised physical and emotional health outcomes. In the past decade, refining the processes related to transition of care for adolescents with chronic medical conditions has gained traction as an important public health initiative. The aim of this paper is to review concepts pertinent to transition of management for adolescents and young adults with IBD, and to review the current literature and evidence supporting transitional care in paediatric IBD.

Transition care: future directions in education, health policy, and outcomes research

All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined. Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success. In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes.

The Postpediatrician Transition

A variety of factors impacts the transition from childhood to adulthood for persons with special health care needs or disabilities. Among these are the barriers in care coordination associated with our bifurcated health care delivery system in which pediatric medicine does not smoothly link up with the medical care received by adults. After reviewing the literature, we discuss the strong case to be made for reconceptualizing the medical home model, introducing a life span perspective to resolve the postpediatrician transition. Rather than a “hand off” from pediatrician to adult provider, this approach provides a pathway to fully integrating this patient population into our evolving health care system.