Facilitating the transition of adolescents with developmental disabilities: nursing practice issues and care

Emergency Department Use by Young Adults With Chronic Illness Before and During the COVID-19 Pandemic

INTRODUCTION

There was a significant decrease in emergency department encounters during the COVID-19 pandemic. Our large urban emergency department observed decreased encounters and admissions by youths with chronic health conditions. This study aimed to compare the frequency of emergency department encounters for certain young adults before the pandemic and during the COVID-19 pandemic.

METHODS

A retrospective cohort study using medical records of patients ages 20 to 26 years from October 2018 to September 2019 and February 2020 to February 2021. Files set for inclusion were those with a primary diagnosis of human immunodeficiency virus, diabetes mellitus, epilepsy, cerebral palsy, sickle cell disease, asthma, and certain psychiatric disorders for potentially preventable health events.

RESULTS

We included 1203 total encounters (853 before the pandemic and 350 during the pandemic), with the total number of subjects included in the study 568 (293 before the pandemic to 239 during the pandemic). During the pandemic, young adults with mental health conditions (53.1%) accounted for most encounters. Encounters requiring hospital admissions increased from 27.4% to 52.5% during the pandemic, primarily among patients with diabetes (41.8% vs 61.1%) and mental health conditions (50% vs 73.3%).

DISCUSSION

The number of young adults with certain chronic health conditions decreased during COVID-19, with encounters for subjects with mental health conditions increasing significantly. The proportion of admissions increased during the pandemic with increases for subjects with mental health disorders and diabetes. The number of frequent users decreased during COVID-19. Future research is needed to understand better the causes for these disparities in young adults with chronic conditions who use the emergency department as a source of care.

Nursing care for persons with developmental disabilities: Review of literature on barriers and facilitators faced by nurses to provide care

AIMS

To identify barriers and facilitators to nursing care of individuals with developmental disabilities (DDs).

BACKGROUND

Individuals with DDs experience health disparities. Nurses, although well positioned to provide optimal care to this population, face challenges.

DESIGN

Narrative review of extant published peer-reviewed literature.

DATA SOURCES

Electronic databases, ProQuest and EBSCO, were searched for studies published in English between 2000 and 2019.

REVIEW METHODS

Three reviewers reviewed abstracts and completed data extraction. Knowledge synthesis was completed by evaluating the 17 selected studies.

RESULTS

Emerging themes were: (1) barriers and challenges to nursing interventions; (2) facilitators to nursing care; and (3) recommendations for nursing education, policy and practice.

CONCLUSION

Nursing has the potential to be a key partner in supporting the health of people with DDs.

IMPACT

There is a need for specific education and training, so nurses are better equipped to provide care for people with DDs.

Development and Initial Testing of a Health-Related Independence Measure for Autistic Young Adults as Reported by Caregivers

Background

Becoming an adult comes with education, work, living, and health-related transitions. Health care transition (HCT) services help adolescents prepare for a smooth transition to adult care, ensure health insurance retention, and promote adolescents' independent management of health care and life needs. Lack of HCT services can result in negative outcomes such as unmet needs, overmedication, and loss of decision-making authority. Autistic young adults (AYA) are half as likely to receive HCT services compared with special needs young adults. Furthermore, there are no HCT readiness measures that address the unique needs of AYA.

Methods

This study used a mixed-methods approach to develop and test a holistic caregiver-reported measure of HCT readiness for AYA Health-Related Independence (HRI). The phases used to create and test the HRI measure included: (1) construct and question topic development through qualitative data collection with AYA and caregivers; (2) question development with clinicians and caregivers; and (3) initial question testing utilizing cognitive interviews and pretesting of the instrument with caregivers.

Results

Measure constructs were developed based on qualitative findings from AYA (n = 27) and caregivers (n = 39). The researchers identified 12 themes related to HRI from the data. Next, questions were developed for each theme by caregivers (n = 5) and clinicians (n = 25). Finally, questions and the survey format were tested using caregiver feedback in the form of cognitive interviews (n = 15) and pretests (n = 21). The final version of the caregiver-reported HRI measure included 8 constructs and 58 questions.

Conclusion

The development of the HRI measure was a comprehensive and iterative process. This article highlights the measurement development process and its potential impact on AYA, caregivers, and clinicians.

Lay summary

Why was this study done?: Health care transition services help youth keep their health insurance, transition to an adult doctor smoothly, and promote independence. To date, there is no health care transition intervention for autistic young adults. Few studies have examined how to prepare autistic young adults to manage their health and self-care needs and the transition to an adult model of care. We wanted to fill in these gaps by creating a measure of health care transition readiness for autistic young adults.What was the purpose of this study?: The purpose of the study was to develop the Health-Related Independence measure based on autistic young adult and caregiver input. We define Health-Related Independence as a young adult's ability to manage their health, healthcare, and safety needs. We also wanted to examine the measure to make sure it was easy to read, made sense, and was easy to answer.What did the researchers do?: We used a mixed-methods approach to develop and test the Health-Related Independence measure. There were three parts to the study: (1) we conducted individual interviews with autistic young adults and focus groups with caregivers to understand what topics should be included in the measure, (2) clinicians and caregivers then used those topics to create specific survey questions, (3) we conducted interviews and online pretest of the measure with caregivers.What were the results of the study?: The autistic young adults and caregivers identified twelve topics/themes to include in the Health-Related Independence Measure. Caregiver feedback helped make the measure shorter and easier to understand and complete. The final version of the caregiver-reported HRI measure included 58 questions.What do these findings add to what was already known?: We learned that young adults and caregivers have a broad understanding of health-related independence such as safety and sexuality/relationship knowledge. There weren't any measures to capture these ideas. This study created an important new measure that can be used in healthcare clinics, schools, and at home.What are potential weaknesses in the study?: This study aimed to work with autistic young adults to develop the Health-Related Independence measure, but due to funding and study limitations, we only included young adults in the 1^st phase of the study. Caregivers were used as proxy reporters in phases 2 and 3. Not including autistic young adults in phases 2 and 3 was a weakness of the study. Future research should aim to fully incorporate young adults into the research process. Their views should inform the development of the qualitative interview guides and all portions of the study.How will these findings help autistic adults now or in the future?: The Health-Related Independence measure can help caregivers and health care providers identify areas in which the autistic young adults are successful and areas of needed improvement to assist in the successful transition to adult care and adult life. The authors are currently working on a study proposal to validate the Health-Related Independence measure as a self-assessment tool for young adults to take themselves.

An Environmental Scan of Parent-focused Transition Practices between Neonatal Follow-up and Children's Rehabilitation Services

Purpose: Identify parent-focused transition practices for parents of children born preterm/acutely ill when transitioning from Neonatal Follow-Up Programs (NFUP) to Children's Treatment Centers or Networks (CTCN).Methods: NFUP and CTCN health-care providers participated in an online survey and qualitative interviews. Quantitative data were analyzed using descriptive statistics and qualitative data underwent conventional content analysis.Results: 60 participants (17 sites) from diverse health disciplines completed the survey, and 14 (from 11 of 17 sites) participated in a follow-up interview. Enablers to transition included knowledgeable practitioners, shared services, and family engagement; although not present across all sites. Barriers commonly reported were a lack of time, understanding of roles, and parent engagement.Conclusion: Research study findings highlight the need to improve and bridge NFUP to CTCN parent-focused transition practices. Recommendations for next actions steps include improved cross-sector communication, bridging sectors through enhanced service provision, and moving from information provision to family engagement.

Transitions from child to adult health care for young people with intellectual disabilities: A systematic review

AIMS

To examine the experiences of health transitions for young people with intellectual disabilities and their carers and identify the implications for nursing practice.

DESIGN

A systematic review and critical appraisal of qualitative, quantitative, and mixed methods studies.

DATA SOURCES

A search of the relevant literature published 2007-2017 was carried out in AMED, ASSIA, CINAHL, MEDLINE, PsycINFO, PubMed, and Science Direct Sociological Abstracts databases.

REVIEW METHODS

A total of 12 of 637 papers identified in the search met the inclusion criteria for this review. A narrative review of the papers was undertaken by synthesizing the key findings and grouping them into concepts and emergent themes.

RESULTS

Four main themes were identified: (a) becoming an adult; (b) fragmented transition process and care; (c) parents as advocates in emotional turmoil; and (d) making transitions happen.

CONCLUSION

The range of issues that have an impact on the transition from child to adult health services for young people with intellectual disabilities and their carers raise important implications for policy development, nursing practice, and education.

Healthcare Transition Readiness, Family Support, and Self-management Competency in Korean Emerging Adults with Type 1 Diabetes Mellitus

PURPOSE

The current study investigated factors related to healthcare transition readiness, including family support and self-management competency, in emerging adults with Type 1 diabetes mellitus (T1DM).

DESIGN AND METHODS

A cross-sectional survey was conducted with 87 individuals, aged 16-24 years. Participants were recruited both from the outpatient clinic of Severance Children's Hospital, and an online self-help group for emerging adults with T1DM in South Korea. Participants reported perceived levels of family support, self-management competency, and healthcare transition readiness through a structured questionnaire.

RESULTS

Healthcare transition readiness was positively correlated with family support (r = 0.257, p = .016) and self-management competency (r = 0.606, p < .001). Multivariate linear regression analyses revealed that only self-management competency was a significant factor associated with healthcare transition readiness (β = 0.699, p < .001).

CONCLUSIONS

For emerging adults with T1DM, ongoing family involvement in diabetes care and enhanced self-management competency can strengthen their healthcare transition readiness. Furthermore, primary factors associated with healthcare transition readiness in the present study were identified as self-management competency and participants' age.

PRACTICE IMPLICATIONS

Healthcare providers should assess and enhance healthcare transition readiness in emerging adults with T1DM. A primary method of addressing transition readiness is helping people strengthen their self-management competency.

Looking back to move forward: Reflections and lessons learned about transitions to adulthood for youth with disabilities

BACKGROUND

Transition to adulthood is a significant development process experienced by all youth. Since the mid 1990s, researchers at the CanChild Centre for Childhood Disability Research have been studying this process to assist transitioning youth with disabilities and their families. The objective of this narrative review is to reflect on the work conducted by CanChild researchers, in collaboration with stakeholders, about transitions to adulthood for youth and young adults with disabilities since the publication of the best practice guidelines in 2009.

METHODS

A narrative review was undertaken through a reflective approach to critically review and summarize all the transition studies completed at CanChild since 2009. The following data were systematically extracted from articles and research reports: study (authors and year of publication), purpose, methods, sample, and lessons learned.

RESULTS

Five studies were identified. An analysis of the findings revealed five key themes that represented lessons learned since the publication of the Ontario-based best practice guidelines: promoting a noncategorical and lifecourse approach to care; active collaboration among stakeholders involved in transition; capacity building through peer mentorship; greater understanding of the significance of opportunities and experiences; as well as the significance of information, education, and research.

CONCLUSIONS

This is the first review to provide perspective on trends in transition research since the publication of the best practice guidelines in 2009. It is hoped that this reflection will assist in the ongoing work of researchers, service providers, policy makers, communities, and families in the area of adult transitions for youth with disabilities.

"It's just going to a new hospital … that's it." Or is it? An experiential perspective on moving from pediatric to adult cancer services

BACKGROUND

Survivors of childhood cancer will, at some stage, move from pediatric to adult care and/or to a different model of care to continue to receive long-term follow-up. Literature relating to transitional care for childhood onset conditions exists, but little research has been undertaken into transition in a cancer context, specifically from an experiences perspective.

OBJECTIVE

The aim of this study was to report how the process of transition should be considered within the context of young people's entire illness experience and how that experience can impact their transition readiness.

INTERVENTION/METHODS

A qualitative, collective case study approach was adopted. Semistructured interviews were conducted with young people, parents, and healthcare professionals. Young people's oncology case notes were also reviewed.

RESULTS

Data analysis generated a multidimensional and multiple-perspective understanding of the experience of the process of transition. A central orienting theme was identified: the experience of readiness in the context of transition.

CONCLUSIONS

Understanding the multifaceted components of readiness is crucial; readiness should embody people's illness experiences, the numerous and associated losses intertwined with a move from pediatric to adult care, and the simultaneous developmental changes occurring in people's lives.

IMPLICATIONS FOR PRACTICE

The findings provide a meaningful framework to understand the experience of transition from the perspective of young people, parents, and healthcare professionals. These findings could help with the planning and preparation of individualized transitional care pathways for survivors of childhood cancer.

You never transition alone! Exploring the experiences of youth with chronic health conditions, parents and healthcare providers on self-management

BACKGROUND

Recent evidence suggests that fostering strategies to enable youth with chronic health conditions to work towards gradual self-management of their health is key in successful transition to adult healthcare. To date, there is limited research on self-management promotion for youth. The purpose of this study is to explore self-management from the perspectives of youth, parents and healthcare providers in transition to adult healthcare.

METHODS

Part of a larger longitudinal transition (TRACE-2009-2013) study, interpretive phenomenology was used to explore the meaning of the lived experiences and perceptions of youth, parents, and healthcare providers about transition to adult healthcare. Purposeful sampling was utilized to select youth with a range of chronic health conditions from the TRACE cohort (spanning 20 diagnoses including developmental disabilities and chronic conditions), their parents and healthcare providers.

RESULTS

The emerging three themes were: increasing independence of youth; parents as safety nets and healthcare providers as enablers and collaborators. The findings indicate that the experiences of transitioning youth, parents and service providers are interconnected and interdependent.

CONCLUSIONS

Results support a dynamic and developmentally appropriate approach when working with transitioning youth and parents in practice. As youth depend on parents and healthcare providers for support in taking charge of their own health, parents and healthcare providers must work together to enable youth for self-management. At a policy level, adequate funding, institutional support and accreditation incentives are recommended to allow for designated time for healthcare providers to foster self-management skills in transitioning youth and parents.

Incorporating the Six Core Elements of Health Care Transition Into a Medicaid Managed Care Plan: Lessons Learned From a Pilot Project

This pediatric-to-adult health care transition pilot project describes the process and results of incorporating the "Six Core Elements of Health Care Transition (2.0)" into a Medicaid managed care plan with a group of 35 18-23 year olds who have chronic mental health, developmental, and complex medical conditions. The pilot project demonstrated an effective approach for customizing and delivering recommended transition services. At the start of the 18-month project, the Medicaid plan was at the basic level (1) of transition implementation of the Six Core Elements with no transition policy, member transition readiness assessment results, health care transition plans of care, updated medical summaries, transfer package for the adult-focused provider, and assurance of transfer completion and consumer feedback. At the conclusion of the pilot project, the plan scored at level 3 on each core element. The primary reason for not scoring at the highest level (4) was because the transition elements have not been incorporated into services for all enrollees within the plan. Future efforts in managed care will benefit from starting the transition process much earlier (ages 12-14), expanding the role of nurse care managers and participating pediatric and adult-focused clinicians in transition, and offering payment incentives to clinicians to implement the Six Core Elements of Health Care Transition.

Measuring Acuity and Patient Progress for Youth With Special Health Care Needs in Transition Care Utilizing Nursing Outcomes

Implementation of a nursing outcomes classification system (NOC) for youth with special health care needs (YSHCN) to support a transition care program may help describe the acuity and measure effectiveness of outcomes. Legislation mandates that care for YSHCN demonstrates effective coordination of care that is patient centered and age appropriate. Transition programs are recommended by leading authorities. In order to provide fair and equable care a universal rating process needs to be implemented to describe the patients' functional status and progress. NOC has the potential to measure patient acuity and outcomes for YSHCN that potentially may guide care needs.

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.

Parent and youth priorities during the transition to adulthood for youth with special health care needs and developmental disability

Families undertake extensive planning during transition to adulthood so youth with concomitant special health care needs and developmental disabilities will have a long-term high quality of life. Findings from an interpretive field study involving 64 youth and their parents indicated that the meaning of adulthood was functioning as independently as possible with appropriate supports. Parental priorities included protecting health, assuring safety and security in multiple realms, finding meaningful activities after high school, and establishing supportive social relationships. These priorities demonstrated the need to broaden usual health care transition goals that focus on finding adult providers and optimizing self-management.

Systems thinking perspectives applied to healthcare transition for youth with disabilities: a paradigm shift for practice, policy and research

BACKGROUND

Healthcare transition (HCT) for youth with disabilities is a complex phenomenon influenced by multiple interacting factors, including health, personal and environmental factors. Current research on the transition to adulthood for disabled youth has primarily focused on identifying these multilevel factors to guide the development of interventions to improve the HCT process. However, little is known about how this complex array of factors interacts and contributes to successful HCT. Systems thinking provides a theoretically informed perspective that accounts for complexity and can contribute to enhanced understanding of the interactions among HCT factors. The objective of this paper is to introduce general concepts of systems thinking as applied to HCT practice and research.

METHODS

Several systems thinking concepts and principles are introduced and a discussion of HCT as a complex system is provided. Systems dynamics methodology is described as one systems method for conceptualizing HCT. A preliminary systems dynamics model is presented to facilitate discourse on the application of systems thinking principles to HCT practice, policy and research.

CONCLUSIONS

An understanding of the complex interactions and patterns of relationships in HCT can assist health policy makers and practitioners in determining key areas of intervention, the impact of these interventions on the system and the potential intended and unintended consequences of change. This paper provides initial examination of applying systems thinking to inform future research and practice on HCT.

The missing link: paediatric to adult transition in diabetes services

Childhood diabetes is a chronic and life-changing condition requiring careful management by clinicians, the child and family. During childhood, care is provided by the paediatric team, which is then transferred to the adult diabetes team during adolescence. This literature review identified five themes in the literature: adolescence as a time of transition; adolescent needs during transition; barriers; facilitators; and models of transition. Key findings suggest that the transition process remains problematic with a gap between paediatric and adult services being identified, including significant differences in clinical practice and culture. Although there is a growing body of knowledge around the reasons behind this phenomenon, research into effective models of transition to address these problems is still lacking. A period of managed transition between the two services has been recommended, with evidence that the nurse has the potential to develop a coordinating role, to assist in bridging the gap between paediatric and adult services.

Medical home and transition planning for children and youth with special health care needs

Although many physicians may practice medical home medicine, most of the health care system is set up for acute episodic care. For children and youth with special health care needs (CYSHCN), this is costly and inefficient care and unsatisfactory for the patient and family. Transition or the purposeful planned movement of adolescents and young adults with chronic conditions from child-centered to adult-centered care began to evolve in the 1980s as more and more CYSHCN survived into adulthood. There is some progress being made in the implementation of the medical home that may facilitate a more effective transition of young individuals who have developmental disabilities. The greatest barrier to successful transition remains ensuring affordable, continuous health insurance coverage for all young people with special health care needs throughout adolescence and adulthood and engaging adult-oriented health care systems to take over the medical care of these young individuals.

Transition of care in children with chronic disease

Healthcare teams need to adapt to change as much as patients and their families