Health care transitions among youth with disabilities or special health care needs: an ecological approach

Transition from child to adult services for young people with cerebral palsy in Ireland: Influencing factors at multiple ecological levels

AIM

To explore the factors that influence the process of transitioning from child to adult services in Ireland among young people with cerebral palsy, their parents, and service providers.

METHOD

This study followed a qualitative descriptive approach. Semi-structured interviews were conducted with 54 participants, including young people with cerebral palsy aged 16 to 22 years (n = 13), their parents (n = 14), and service providers (n = 27). Data were analysed using the Framework Method. Findings were categorized using an ecological model across four levels: individual, microsystem, mesosystem, and exosystem.

RESULTS

Limited awareness, preparation, and access to information hindered successful transition. Microsystem factors such as family knowledge, readiness, resilience, and health professional expertise influenced transition experience. Mesosystem factors encompassed provider-family interaction, interprofessional partnerships, and interagency collaboration between child and adult services. Exosystem factors included inadequate availability and distribution of adult services, limited referral options, coordination challenges, absence of transition policies, staffing issues, and funding allocation challenges.

INTERPRETATION

Transition is influenced by diverse factors at multiple ecological levels, including interactions within families, between health professionals, and larger systemic factors. Given the complexity of transition, a comprehensive multi-level response is required, taking into account the interactions among individuals, services, and systems.

Latin-American consensus on the transition into adult life of patients with X-linked hypophosphatemia

INTRODUCTION

X-linked hypophosphatemia is an orphan disease of genetic origin and multisystem involvement. It is characterized by a mutation of the PHEX gene which results in excess FGF23 production, with abnormal renal and intestinal phosphorus metabolism, hypophosphatemia and osteomalacia secondary to chronic renal excretion of phosphate. Clinical manifestations include hypophosphatemic rickets leading to growth abnormalities and osteomalacia, myopathy, bone pain and dental abscesses. The transition of these patients to adult life continues to pose challenges to health systems, medical practitioners, patients and families. For this reason, the aim of this consensus is to provide a set of recommendations to facilitate this process and ensure adequate management and follow-up, as well as the quality of life for patients with X-linked hypophosphatemia as they transition to adult life.

MATERIALS AND METHODS

Eight Latin American experts on the subject participated in the consensus and two of them were appointed as coordinators. The consensus work was done in accordance with the nominal group technique in 6 phases: (1) question standardization, (2) definition of the maximum number of choices, (3) production of individual solutions or answers, (4) individual question review, (5) analysis and synthesis of the information and (6) synchronic meetings for clarification and voting. An agreement was determined to exist with 80% votes in favor in three voting cycles.

RESULTS AND DISCUSSION

Transition to adult life in patients with hypophosphatemia is a complex process that requires a comprehensive approach, taking into consideration medical interventions and associated care, but also the psychosocial components of adult life and the participation of multiple stakeholders to ensure a successful process. The consensus proposes a total of 33 recommendations based on the evidence and the knowledge and experience of the experts. The goal of the recommendations is to optimize the management of these patients during their transition to adulthood, bearing in mind the need for multidisciplinary management, as well as the most relevant medical and psychosocial factors in the region.

Elucidating the Perspectives of Autistic Youth About Their Health Care Experiences: A Qualitative Study

OBJECTIVES

Autistic individuals have higher rates of co-occurring medical conditions and service use. However, autistic individuals and their families also reported lower satisfaction with health care service delivery. Previous studies described health care experiences of autistic adults, but less is known about those of autistic adolescents and young adults. This study aimed to qualitatively describe the health care experiences of autistic youth.

METHODS

Four longitudinal/serial focus groups were conducted with 8 autistic adolescents and young adults. Participants were members of an autistic patient advisory board, which is part of a broader initiative at a large, urban, safety-net hospital to improve the health care experiences of autistic patients. Focus groups were conducted virtually and were audio-recorded. Audio recordings were transcribed and verified for accuracy. Transcripts were consensus-coded with an inductive approach using tenets of grounded theory.

RESULTS

Findings included 4 recurring themes: accessibility and accommodations, barriers of health service use, patient involvement in health care decisions, and facilitators of patient-clinician relationship. Participants noted that visit preparation, sensory items, and repeated positive interactions with clinician were helpful to build a positive health care experience.

CONCLUSION

Our findings support previous research that suggest the need to individualize care, ensure availability of accommodations, apply flexibility in practice whenever possible, and increase health care professional knowledge about this unique patient population.

The role and the composition of a liaison team to facilitate the transition of adolescents and young adults: an umbrella review

Adolescents and young adults (AYAs) benefit from healthcare transition (HCT) programs. Despite the well-established literature reviewing HCT, a considerable heterogeneity exists on the involved healthcare professionals. This review aims to explore systematic reviews on the practices and recommendations on which disciplines of professionals should be involved in HCT. An umbrella review was performed using the MEDLINE, EMBASE, and Web of Science databases. To be eligible, systematic reviews had to report on the composition and/or the rationale of members of a transition team. Seventeen reviews were included in this systematic review. A healthcare professional that coordinates HCT was identified as a key caregiver in all reviews. Other reported members of a HCT team were nurses (75% of the reviews), social workers (44%), and peers/mentors (35%). The reported key responsibilities of a HCT team were to (i) manage communication, (ii) ensure continuity of care, and (iii) maintain contact with community services.  Conclusions: A team responsible for HCT should be active on the organizational, medical, and social levels. Key members of a HCT team vary little between diseases and included a coordinator, social worker, and nurse. A coordinating physician could facilitate transition in complex conditions. At all times, the condition and needs of the AYA should determine who should be involved as caregiver. What is Known: • The psychosocial needs of adolescents and young adults during healthcare transition are largely similar between chronic diseases. What is New: • Coordinators, nurses and social workers were the most involved, independent of the condition. • A liaison team should be active on organizational-, medical- and social-levels.

Programmes to support paediatric to adult healthcare transitions for youth with complex care needs and their families: A scoping review

BACKGROUND

An increasing number of children have complex care needs (CCN) that impact their health and cause limitations in their lives. More of these youth are transitioning from paediatric to adult healthcare due to complex conditions being increasingly associated with survival into adulthood. Typically, the transition process is plagued by barriers, which can lead to adverse health consequences. There is an increased need for transitional care interventions when moving from paediatric to adult healthcare. To date, literature associated with this process for youth with CCN and their families has not been systematically examined.

OBJECTIVES

The objective of this scoping review is to map the range of programmes in the literature that support youth with CCN and their families as they transition from paediatric to adult healthcare.

METHODS

The review was conducted in accordance with the Joanna Briggs Institute's methodology for scoping reviews. A search, last run in April 2021, located published articles in PubMed, CINAHL, ERIC, PsycINFO and Social Work Abstracts databases.

RESULTS

The search yielded 1523 citations, of which 47 articles met the eligibility criteria. A summary of the article characteristics, programme characteristics and programme barriers and enablers is provided. Overall, articles reported on a variety of programmes that focused on supporting youth with various conditions, beginning in the early or late teenage years. Financial support and lack of training for care providers were the most common transition program barriers, whereas a dedicated transition coordinator, collaborative care, transition tools and interpersonal support were the most common enablers. The most common patient-level outcome reported was satisfaction.

DISCUSSION

This review consolidates available information about interventions designed to support youth with CCN transitioning from paediatric to adult healthcare. The results will help to inform further research, as well as transition policy and practice advancement.

Perspectives About Transition Readiness Among Adolescents and Young People Living With Perinatally Acquired HIV in Rural, Southwestern Uganda: A Qualitative Study

ABSTRACT

Despite the availability of antiretroviral therapy, treatment outcomes are worse among adolescents and young adults living with perinatally acquired HIV (AYLPHIV). These disparities are magnified during the transition from pediatric to adult-based HIV care. We conducted in-depth interviews with AYLPHIV aged 15-24 years ( n = 30), their caregivers ( n = 10), and health care providers ( n = 10). All participants provided written assent and/or informed consent to enroll. Thematic content analysis was used to identify and analyze themes relevant to transition readiness. We grouped perspectives on transition readiness into 4 themes: preparation for transition, communication between stakeholders, social support, and timing of transition. AYLPHIV in sub-Saharan Africa who are facing a transition to adult HIV care should be equipped with relevant information about their illness, self-advocacy skills, and support from caregivers and health care providers to remain engaged in HIV care.

Transition Navigator Intervention Improves Transition Readiness to Adult Care for Youth With Sickle Cell Disease

OBJECTIVE

Adolescents and young adults (AYA) with sickle cell disease (SCD) experience high rates of acute care utilization and increased morbidity. At this high-risk time, they also face the need to transition from pediatric to adult services, which, if poorly coordinated, adds to heightened morbidity and acute care utilization. The study objective was to characterize the feasibility, acceptability, and short-term efficacy of a protocolized transition navigator (TN) intervention in AYA with SCD.

METHODS

We developed a protocolized TN intervention that used ecological assessment and motivational interviewing to assess transition readiness, identify goals, and remove barriers to transition, and to provide disease and pain management education and skills to AYAs with SCD.

RESULTS

Ninety-three percent (56/60) of enrolled individuals completed the intervention. Participation in the TN program was associated with significant improvement in mean transition readiness scores (3.58-4.15, P < .0001), disease knowledge scale (8.91-10.13, P < .0001), Adolescent Medication Barriers Scale (40.05-35.39, P = .003) and confidence in both disease (22.5-23.96, P = .048) and pain management (25.07-26.61, P = .003) for youth with SCD.

CONCLUSION

The TN intervention was acceptable to youth with SCD, feasible to implement at an urban academic medical center, and addressed barriers to transition identified by the youth. Longer-term assessment is needed to determine if the TN intervention improved successful transfer to and retention in adult care.

Healthcare Access and Utilization for Young Adults With Disability: U.S., 2014-2018

PURPOSE

Young adults with disability experience barriers to healthcare access and are at risk for not receiving needed services as they transition from pediatric to adult health systems. This study examined patterns of healthcare utilization for young adults with disability and potential barriers to receipt of care.

METHODS

Data from the 2014 to 2018 National Health Interview Survey were analyzed to examine differences in service utilization, unmet need, care satisfaction, and financial worry between young adults (18-30 years) with and without disability (unweighted n = 15,710). Odds ratios were adjusted for individual, family, and interview characteristics.

RESULTS

Compared to those without disability, young adults with disability were more likely to have had an emergency room visit in the past year (39.2% vs. 19.5%). They were also more likely to have a usual source of care when sick (82.2% vs. 75%). Among young adults who affirmed they had a usual place of care, those with disability were more likely to use the emergency room as their usual place of care (5.3% vs. 1.8%). A greater percentage of young adults with disability delayed medical care due to cost (19.1% vs. 8.9%) and reported an unmet medical need (21% vs. 10.2%).

CONCLUSIONS

Findings highlight gaps in healthcare access for young adults with disability. Differences in healthcare utilization patterns for young adults with disability and factors that may negatively influence health outcomes for this population were found. Further research focused on the continuity of healthcare services in this age group through the healthcare transition period may provide additional insight into these discrepancies.

Adolescents and Young Adults With Spina Bifida Transitioning to Adulthood: A Comprehensive Community-Based Needs Assessment

OBJECTIVE

Developing effective interventions to promote successful transition to adulthood for adolescents and young adults (AYA) with spina bifida (SB) requires input from SB community stakeholders, particularly AYA themselves. The goal of this study was to identify and prioritize facilitators and barriers of successful transition to a healthy adult life for AYA with SB.

METHODS

We utilized concept mapping, a community-engaged research methodology. We recruited a purposeful sample of SB community stakeholders: AYA with SB, parents/caregivers, pediatric and adult health care providers, and community organizations. Participants generated ideas to open-ended prompts. A subset of participants sorted responses into groups of similar ideas. Multidimensional scaling and hierarchical cluster analysis were applied to generate cluster maps. The concept map was determined by identifying the optimal cluster number that qualitatively represented meaningful and distinct concepts. Concepts were rated by participants for importance and feasibility.

RESULTS

Participants generated 90 unique ideas that were then sorted. The research team chose a 10-cluster concept map: coordinated and comprehensive medical care, health and wellness, self-management, self-advocacy, skills to maximize independence, inclusivity and relationship supports, physical accessibility of the environment, employment, finances, and community- and school-based resources. Self-management, self-advocacy, and inclusivity and relationship supports were rated as both highly feasible and important.

CONCLUSIONS

By using concept mapping to engage diverse stakeholders, including people with intellectual, development, and physical disabilities, this study prioritized less traditional areas like inclusivity and relationship supports to focus improvement efforts relevant to AYA with SB becoming healthy adults.

"Because we all have to grow up": supporting adolescents in Uganda to develop core competencies to transition towards managing their HIV more independently

INTRODUCTION

Sustaining optimal adherence is the major challenge facing adolescents living with HIV (ALHIV), particularly in low-resource settings, where "second-line" is often the last accessible treatment option. We explored the knowledge and skills adolescents need in order to maintain improved adherence behaviours, and the specific ways clinicians and caregivers may support young people to do so more independently.

METHODS

We conducted individual, in-depth interviews with 20 ALHIV aged 10 to 18 years in Uganda in 2017 to 2018. All participants had recently commenced second-line treatment as part of a clinical trial. We used thematic qualitative analysis to examine adherence experiences and challenges while on first-line therapy, as well as specific supports necessary to optimise treatment-taking longer-term.

RESULTS

Adherence difficulties are exacerbated by relatively rapid shifts from caregiver-led approaches during childhood, to an expectation of autonomous treatment-taking with onset of adolescence. For many participants this shift compounded their ongoing struggles managing physical side effects and poor treatment literacy. Switching to second-line typically prompted reversion back to supervised adherence, with positive impacts on self-reported adherence in the immediate term. However, this measure is unlikely to be sustainable for caregivers due to significant caregiver burden (as on first line), and provided little opportunity for clinicians to guide and develop young people's capacity to successfully adopt responsibility for their own treatment-taking.

CONCLUSIONS

As ALHIV in sub-Saharan Africa are attributed increasing responsibility for treatment adherence and HIV management, they must be equipped with the core knowledge and skills required for successful, self-directed care. Young people need to be relationally supported to develop necessary "adherence competencies" within the supportive framework of a gradual "transition" period. Clinic conversations during this period should be adolescent-focussed and collaborative, and treatment-taking strategies situated within the context of their lived environments and support networks, to facilitate sustained adherence. The disclosure of adherence difficulties must be encouraged so that issues can be identified and addressed prior to treatment failure.

An Evidence Map for Interventions Addressing Transition from Pediatric to Adult Care: A Systematic Review of Systematic Reviews

PROBLEM

Adolescents and young adults with chronic illnesses continue to face barriers as they transition from pediatric to adult care. An evidence map can help to identify gaps in the transition literature to determine targets for future research.

ELIGIBILITY CRITERIA

We searched PubMed, CINAHL, PsycInfo, and Cochrane for systematic reviews published through February 2018. Eligible reviews included at least one comparative study testing a youth-focused intervention for improving transition with at least one quantitative health-related outcome reported.

SAMPLE

We identified 431 unique reviews in our search, and 37 reviews (containing 71 eligible primary studies) met inclusion criteria.

RESULTS

Most reviews (20 of 37) summarized some aspect of transition across diagnoses. Type 1 diabetes was the most common diagnosis studied (7 of 37 reviews and 24 of 71 primary studies). Only 14 of 71 primary studies focused on care after transfer to adult care.

CONCLUSIONS

The literature on interventions to improve transition to adult care has focused on a limited number of diagnoses, most commonly Type 1 diabetes. Common pediatric conditions, such as asthma, have not been studied with regard to transition. Efforts have been mainly targeted on transition preparation, with less focus on transition needs after transfer to adult care.

IMPLICATIONS

There is a need for transition research focused on common pediatric conditions and transition needs after transfer to adult care.

Utilization of Physical Therapy Services During Transition for Young People With Cerebral Palsy: A Call for Improved Care Into Adulthood

BACKGROUND

Many young adults with cerebral palsy (CP) face limited participation in activities, including employment and independent living. Physical therapy during the transition period can help to support participation through promotion of self-care, ambulation, and functional mobility. Thus, ensuring appropriate access to physical therapy services for young people who can benefit from them before, during, and after transition is imperative.

OBJECTIVE

The objective of this study was to identify factors contributing to the utilization of physical therapy services for youth with CP both during and after secondary school.

DESIGN

The design was a deidentified secondary analysis of the National Longitudinal Transition Study 2 (NLTS2).

METHODS

Multivariate regression models were run to examine demographic and disability characteristics influencing utilization of physical therapy services for youth with CP both during and after secondary school.

RESULTS

The total weighted population sample included 35,290 young people with CP. When all youth were in secondary school, 59.4% of the youth utilized physical therapy services; however, once all youth were out of school, only 33.7% of them were reported to have utilized physical therapy since leaving secondary school. For young people with difficulties accessing general disability support services, demographic characteristics, including sex, race, income, and parent education status, influenced use of physical therapy services in addition to disability characteristics.

LIMITATIONS

This population sample included only young people in special education with Individual Education Plans (IEPs) and may not generalize to young people with CP in general education settings.

CONCLUSIONS

Frequency of physical therapy services decreases drastically once young adults with CP leave secondary school. Future work should examine this trend in more depth to identify therapy intervention strategies to optimize participation in young adult life for persons with CP.

Why is transition between child and adult services a dangerous time for young people with chronic kidney disease? A mixed-method systematic review

Young people age 14-25 years with chronic kidney disease have been identified as generally having poor health outcomes and are a high-risk group for kidney transplant loss due in part to poor self-management. This raises a key question as to what happens during transition from child to adult services? This paper presents a mixed-method systematic review of health and social care evidence concerning young people with chronic kidney disease transitioning from child to adult health and social care services. Quantitative and qualitative evidence were synthesised in streams followed by an overarching synthesis. Literature searches (2000 to March 2017) were conducted using Pubmed, BioMed Central and Cochrane Library, grey literature sources ZETOC, .gov.uk, third sector organisations, NHS Evidence, SCIE, TRIP, Opengrey. Snowball searching was conducted in the databases Ovid, CINAHL, ISI Web of Science, Scopus and Google Scholar. Of 3,125 records screened, 60 texts were included. We found that while strategies to support transition contained consistent messages, they supported the principle of a health-dominated pathway. Well-being is mainly defined and measured in clinical terms and the transition process is often presented as a linear, one-dimensional conduit. Individual characteristics, along with social, familial and societal relationships are rarely considered. Evidence from young people and their families highlights transition as a zone of conflict between independence and dependency with young people feeling powerless on one hand and overwhelmed on the other. We found few novel interventions and fewer that had been evaluated. Studies were rarely conducted by allied health and social care professionals (e.g. renal social workers and psychologists) as part of multi-disciplinary renal teams. We conclude that there is a lack of good evidence to inform providers of health and social care services about how best to meet the needs of this small but vulnerable cohort.

Using the ICF in transition research and practice? Lessons from a scoping review

BACKGROUND

The International Classification of Functioning, Disability and Health (ICF) and subsequent ICF-CY (child and youth version) recognize the importance of personal and environmental factors in facilitating holistic transition planning and service delivery for youth with chronic health conditions (YCHC).

AIMS

The objective of this scoping review is to investigate the degree to which the ICF and ICF-CY have been used in transition research and practice since its initial publication.

METHODS

Arksey and O'Malley's five-stage methodological framework guided the scoping review using the following databases: AMED, CINAHL, EMBASE, HealthSTAR, MEDLINE, and PsycINFO. Keywords included: 'ICF', 'ICF-CY', and 'transition', which were adapted to each database.

RESULTS

25 articles met final inclusion. Two key themes emerged regarding use of the ICF: 1) the ICF enhances transdisciplinary processes to inform transition planning and interventions; and 2) the ICF facilitates comprehensive and developmentally appropriate transition services over a youth's lifecourse. The strengths and limitations of the ICF in guiding the planning and delivery of transition services are discussed. Some limitations include the large number of items inherent within the ICF and a lack of clarity between the components of activity and participation.

CONCLUSION

Key recommendations include: i) further explanation and development of items for quality of life and well-being, personal factors, and psychological issues; and ii) additional research to advance knowledge towards developing empirically- based evidence for the application of the ICF in clinical practice to facilitate transition.

Health Care Disparities of Ohioans With Developmental Disabilities Across the Lifespan

We explored health care differences across the lifespan comparing people with developmental disabilities to people without developmental disabilities. Health care disparities are inequities occurring during the provision of and in access to health care that are experienced by socially disadvantaged populations. We discovered significant disparities between persons with and without developmental disabilities in health status, quality, utilization, access, and unmet health care needs. Our results highlight the need to educate health care clinicians on the care of patients with developmental disabilities of all ages.

Parenting a child with chronic illness as they transition into adulthood: A systematic review and thematic synthesis of parents' experiences

OBJECTIVE

To understand how parents view and experience their role as their child with a long-term physical health condition transitions to adulthood and adult healthcare services.

METHODS

Five databases were systematically searched for qualitative articles examining parents' views and experiences of their child's healthcare transition. Papers were quality assessed and thematically synthesised.

RESULTS

Thirty-two papers from six countries, spanning a 17-year period were included. Long-term conditions were diverse. Findings indicated that parents view their child's progression toward self-care as an incremental process which they seek to facilitate through up-skilling them in self-management practices. Parental perceptions of their child's readiness, wellness, competence and long-term condition impacted on the child' progression to healthcare autonomy. A lack of transitional healthcare and differences between paediatric and adult services served as barriers to effective transition. Parents were required to adjust their role, responsibilities and behaviour to support their child's growing independence.

CONCLUSION

Parents can be key facilitators of their child's healthcare transition, supporting them to become experts in their own condition and care. To do so, they require clarification on their role and support from service providers.

PRACTICE IMPLICATIONS

Interventions are needed which address the transitional care needs of parents as well as young people.

"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.

Stressors in Teens with Type 1 Diabetes and Their Parents: Immediate and Long-Term Implications for Transition to Self-Management

Teens with Type 1 diabetes and their parents experience every day and illness-related stress; however, understanding of how these stressors relate to the transition to adulthood is limited. The purpose of this study was to identify stressors of teens with Type 1 diabetes (T1DM) and their parents related to the impending transition to adulthood.

DESIGN AND METHODS

This study used open-ended questions to identify every day and illness-related stressors among 15 teens with T1DM and 25 parents seen in one pediatric diabetes clinic. Qualitative descriptive analysis identified themes in interview transcripts.

RESULTS

The primary teen stressor related to impending transition centered on ineffective self-management, often when they were taking over responsibility for T1DM management. Parents' concerns included immediate and long-term negative outcomes of teen self-management as well as financial resources and health insurance for the teen. Teens and parents both expressed specific concerns about outcomes and prevention of nocturnal hypoglycemia, and identified uncertainties related to teen health and diabetes-focused health care when no longer living in the parent's home.

CONCLUSIONS

Teens with Type 1 diabetes and their parents understand that independent teen self-management is a component of transition to adulthood, but worry about teen self-management outcomes. Concerns specific to health care transition included health insurance, T1DM resources, and teens' abilities to handle new situations.

PRACTICE IMPLICATIONS

Identifying current and future self-management concerns of individuals and families can facilitate targeted education and interventions to support successful transition to adulthood.

Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services - an integrative review

AIMS AND OBJECTIVES

This paper aims to provide an updated comprehensive review of the research-based evidence related to the transitions of care process for adolescents and young adults with chronic illness/disabilities since 2010.

BACKGROUND

Transitioning adolescent and young adults with chronic disease and/or disabilities to adult care services is a complex process, which requires coordination and continuity of health care. The quality of the transition process not only impacts on special health care needs of the patients, but also their psychosocial development. Inconsistent evidence was found regarding the process of transitioning adolescent and young adults.

DESIGN

An integrative review was conducted using a five-stage process: problem identification, literature search, data evaluation, data analysis and presentation.

METHODS

A search was carried out using the EBSCOhost, Embase, MEDLINE, PsycINFO, and AustHealth, from 2010 to 31 October 2014. The key search terms were (adolescent or young adult) AND (chronic disease or long-term illness/conditions or disability) AND (transition to adult care or continuity of patient care or transfer or transition).

RESULTS

A total of 5719 records were initially identified. After applying the inclusion criteria a final 61 studies were included. Six main categories derived from the data synthesis process are Timing of transition; Perceptions of the transition; Preparation for the transition; Patients' outcomes post-transition; Barriers to the transition; and Facilitating factors to the transition. A further 15 subcategories also surfaced.

CONCLUSIONS

In the last five years, there has been improvement in health outcomes of adolescent and young adults post-transition by applying a structured multidisciplinary transition programme, especially for patients with cystic fibrosis and diabetes. However, overall patients' outcomes after being transited to adult health care services, if recorded, have remained poor both physically and psychosocially. An accurate tracking mechanism needs to be established by stakeholders as a formal channel to monitor patients' outcomes post- transition.

International and Interdisciplinary Identification of Health Care Transition Outcomes

IMPORTANCE

There is a lack of agreement on what constitutes successful outcomes for the process of health care transition (HCT) among adolescent and young adults with special health care needs.

OBJECTIVE

To present HCT outcomes identified by a Delphi process with an interdisciplinary group of participants.

DESIGN, SETTING, AND PARTICIPANTS

A Delphi method involving 3 stages was deployed to refine a list of HCT outcomes. This 18-month study (from January 5, 2013, of stage 1 to July 3, 2014, of stage 3) included an initial literature search, expert interviews, and then 2 waves of a web-based survey. On this survey, 93 participants from outpatient, community-based, and primary care clinics rated the importance of the top HCT outcomes identified by the Delphi process. Analyses were performed from July 5, 2014, to December 5, 2014.

EXPOSURES

Health care transition outcomes of adolescents and young adults with special health care needs.

MAIN OUTCOMES AND MEASURES

Importance ratings of identified HCT outcomes rated on a Likert scale from 1 (not important) to 9 (very important).

RESULTS

The 2 waves of surveys included 117 and 93 participants as the list of outcomes was refined. Transition outcomes were refined by the 3 waves of the Delphi process, with quality of life being the highest-rated outcome with broad agreement. The 10 final outcomes identified included individual outcomes (quality of life, understanding the characteristics of conditions and complications, knowledge of medication, self-management, adherence to medication, and understanding health insurance), health services outcomes (attending medical appointments, having a medical home, and avoidance of unnecessary hospitalization), and a social outcome (having a social network). Participants indicated that different outcomes were likely needed for individuals with cognitive disabilities.

CONCLUSIONS AND RELEVANCE

Quality of life is an important construct relevant to HCT. Future research should identify valid measures associated with each outcome and further explore the role that quality of life plays in the HCT process. Achieving consensus is a critical step toward the development of reliable and objective comparisons of HCT outcomes across clinical conditions and care delivery locations.

Experiences with and Outcomes of Two Interventions to Maximize Engagement of Chronically Ill Adolescents During Hospital Consultations: A Mixed Methods Study

Improving patient-provider communication during hospital consultations is advocated to enhance self-management planning and transition readiness of adolescents with chronic conditions. This longitudinal mixed methods study evaluates the implementation and the outcomes of independent split-visit consultations and individual transition plans by 22 hospital teams participating in the Dutch Action Program 'On Your Own Feet Ahead!'. The interventions raised awareness in adolescents and professionals, improved adolescents' display of independent behaviors and led to more discussions about non-medical issues. Successful implementation required a team-based approach and clear explanation to parents and adolescents. Pediatric nurses played a pivotal role in improving transitional care.

Multidisciplinary Support for Healthcare Transitioning Across an Urban Healthcare Network

BACKGROUND

A successful transition from pediatric to adult oriented health care is a vital process in maintaining a patient-centered medical home for youth with special health care needs (YSHCNs). We assessed practices of pediatric providers who transition YSCHNs to adult-oriented medical care in a large urban academic healthcare network.

METHODS

A cross-sectional Web-based survey was distributed to 376 generalist and subspecialist pediatric providers. Survey assessed provider-reported utilization of 11 Essential Steps adapted from the 2002 Consensus Statement on Health Care Transitions for YSHCNs, and recent transitioning literature. Compliance score (CS11) was calculated as a sum of steps completed. Additional items assessed knowledge of transitioning literature and respondent demographics.

RESULTS

Survey achieved a 28% response rate (n=105), of whom 84 reported assisting transitioning YSHCNs. Only 16.7% of these respondents were compliant with 7 or more of the 11 Essential Steps. Respondents who identified social work or nursing were more likely to have CS11 scores ≥7 compared to those without and were more likely to be compliant with specific steps.

CONCLUSION

We found limited and incomplete utilization of recommended transitioning steps for YSHCNs by pediatric providers within a large urban healthcare network. Access to support from social work and nursing was associated with greater utilization of specific recommended steps, and with more optimal compliance. Further research needs to assess the transitioning practices of all members of the multidisciplinary team and whether operationalizing healthcare transition for YSHCNs as a multidisciplinary activity impacts the transitioning process and patient outcomes.

Uncharted Territory: Systematic Review of Providers' Roles, Understanding, and Views Pertaining to Health Care Transition

BACKGROUND

Health care transition (HCT) for adolescents and emerging adults (AEA) with special health care needs is an emerging field of interdisciplinary field of practice and research that is based upon an intergenerational approach involving care coordination between pediatric and adult systems of health care. Informed understanding of the state of the HCT science pertaining to this group of providers is needed in order to develop and implement service programs that will meet the comprehensive needs of AEA with special health care needs.

METHODS

The authors conducted a systematic review of the literature on the transition from child to adult care for adolescents and emerging adults (AEA) with special health care needs from 2004 to 2013. Fifty-five articles were selected for this review. An adaptation of the PRISMA guidelines was applied because all studies in this review used descriptive designs.

RESULTS

Findings revealed lack of evidence due to the limitations of the research designs and methodology of the studies included in this systematic review. Study findings were categorized the following four types: adult provider competency, provider perspectives, provider attitudes, and HCT service models. The discipline of medicine was predominant; interdisciplinary frameworks based upon integrated care were not reported. Few studies included samples of adult providers.

CONCLUSIONS

Empirical-based data are lacking pertaining to the role of providers involved in this specialty area of practice. Evidence is hampered by the limitations of the lack of rigorous research designs and methodology.

Transition Needs of Parents of Adolescents and Emerging Adults With Special Health Care Needs and Disabilities

The period of health care transition (HCT) for adolescents and emerging adults with special health care needs and disabilities involves a complex realignment of the parent-child relationship, including alterations in role responsibilities and decision making. The purpose of this systematic review was to analyze the research designs, methodology, and findings reported in studies of parents during this transition period to provide new insights for research and clinical practice. Results showed that parents were unable to clearly envision what the future held for their children and were not well prepared by the service system to anticipate future prospects. These parents have a myriad of needs that are not yet fully understood, as HCT research is in the early stages of development.

Developmentally appropriate healthcare for young people: a scoping study

BACKGROUND

There is increasing recognition of the importance of providing quality healthcare to meet the biopsychosocial needs of young people. 'Developmentally appropriate healthcare' (DAH) for young people is one term used to explain what these services consist of. However, this term remains ill defined.

AIMS

(i) To analyse the use of the term DAH in the scientific literature and (ii) to identify and explore the range of meanings attributed to the term in relation to young people.

METHODS

A scoping review was conducted to map the presence of the term DAH in the literature. To analyse the use and meanings attributed to the DAH terminology, data underwent qualitative content analysis using a summative approach.

RESULTS

62 papers were selected and subjected to content analysis. An explicit definition of DAH was provided in only 1 of the 85 uses of the term DAH within the data set and in none of the 58 uses of the prefix 'developmentally appropriate'. A link between the use of the term DAH and the domains of adolescent medicine, young people, chronic conditions and transitional care was identified; as were the core ideas underpinning the use of DAH.

CONCLUSIONS

There is a need for consistency in the use of the term DAH for young people, the related stage-of-life terminology and age range criteria. Consensus is now needed as to the content and range of a formal conceptual and operational definition.

Medical care transition planning and dental care use for youth with special health care needs during the transition from adolescence to young adulthood: a preliminary explanatory model

The aims of the study were to test the hypotheses that youth with special health care needs (YSHCN) with a medical care transition plan are more likely to use dental care during the transition from adolescence to young adulthood and that different factors are associated with dental utilization for YSHCN with and YSHCN without functional limitations. National Survey of CSHCN (2001) and Survey of Adult Transition and Health (2007) data were analyzed (N = 1,746). The main predictor variable was having a medical care transition plan, defined as having discussed with a doctor how health care needs might change with age and having developed a transition plan. The outcome variable was dental care use in 2001 (adolescence) and 2007 (young adulthood). Multiple variable Poisson regression models with robust standard errors were used to estimate covariate-adjusted relative risks (RR). About 63 % of YSHCN had a medical care transition plan and 73.5 % utilized dental care. YSHCN with a medical care transition plan had a 9 % greater RR of utilizing dental care than YSHCN without a medical care transition plan (RR 1.09; 95 % CI 1.03-1.16). In the models stratified by functional limitation status, having a medical care transition plan was significantly associated with dental care use, but only for YSHCN without functional limitations (RR 1.11; 95 % CI 1.04-1.18). Having a medical care transition plan is significantly associated with dental care use, but only for YSHCN with no functional limitation. Dental care should be an integral part of the comprehensive health care transition planning process for all YSHCN.

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.

Up against the System: A Case Study of Young Adult Perspectives Transitioning from Pediatric Palliative Care

Advances in pediatric care have not provided the interdisciplinary support services required by those young adults with pediatric life-threatening conditions (pedLTCs) who live beyond childhood but have limited expectations to live past early adulthood. These young adults, the first generation to live into adulthood, face multiple challenges transitioning from a plethora of pediatric palliative services to scant adult health services. In a case study, using an innovative bulletin board focus group, we describe the complex interplay of the health, education, and social service sectors in this transition. Our descriptions include system deficits and strengths and the young adults' resilience and coping strategies to overcome those deficits and move forward with their lives. Young adults with pedLTC need knowledgeable providers, coordinated and accessible services, being respected and valued, and services and supports that promote independence. We recommend implementation of multidisciplinary solutions that are focused on young adult priorities to ensure seamless access to resources to support these young adults' health, educational, vocational, and social goals. The input and voice of young adults in the development of these services are imperative to ensure that multisystem services support their needs and life goals.

Transitioning adolescents and young adults with a chronic health condition to adult healthcare - an exemplar program

Pediatric specialists have successfully improved the longevity and quality of life of many children with chronic health conditions. As these children reach adolescence and young adulthood, the scope of their concomitant medical problems often include those typically seen in older patients. As a result, these individuals need continuing quality health care in focused adult healthcare facilities. This article describes the effective partnership between pediatric and adult healthcare providers to create and implement an exemplar Spina Bifida Transition Program. The processes, strategies and tools discussed are likely to be useful to other healthcare professionals interested in developing pediatric to adult transition programs for adolescents and young adults with chronic health conditions.

Future plans and social/recreational activities of youth with special health care needs: the implications of parental help in completing surveys

BACKGROUND

A major focus of the literature on youth with special health care needs (YSHCN) is the transition to adult health care. As perceptions of disability are a product of interactions between youth and their environment, it is important to understand youth's needs and experiences beyond health care. Few studies have addressed social/recreational activity participation and future plans and none have included parent/caregiver help in survey completion as a potential factor impacting responses.

OBJECTIVES

We describe activity participation and identification of future plans among YSHCN and examine the impact of receiving parent/caregiver assistance to complete a survey on these responses. Implications for research, policy, and practice affecting programs serving and providing transition assistance for YSHCN are discussed.

METHODS

Data are from a survey of YSHCN conducted during Alabama's 2010 Title V Maternal and Child Health Needs Assessment. Analyses included descriptive statistics, bivariate analysis, and multivariable logistic regression.

RESULTS

Youth who received help completing the survey were less likely to report participating in certain social/recreational activities and key future plans, including hobbies, getting married, having children, and working for pay.

CONCLUSIONS

For YSHCN, parent/caregiver assistance to complete a survey is a critical consideration in analyses and interpretation of results. Whether, how much, and what type of help received may represent a more objective proxy measure of perceptions of condition severity or impact on abilities than do self-reported ratings of these factors. Our results also raise questions about the distinctions between youth and parent/caregiver perceptions of independence, participation, and potential.

Change in health status and access to care in young adults with special health care needs: results from the 2007 national survey of adult transition and health

BACKGROUND

Despite over 500,000 adolescents with special health care needs transitioning to adulthood each year, limited information is available on their health status or their access to care after transition.

OBJECTIVE

To describe the change in health status and access to care of a nationally sampled, longitudinal cohort of young adults with special health care needs (ASHCN).

METHODS

We analyzed follow-up data collected in the 2007 Survey of Adult Transition and Health on young adults who were 14-17 years of age when their parents participated in the 2001 National Survey of Children with Special Health Care Needs. We describe changes in access to care and health status over time, and used logistic regression to identify characteristics that were associated with declining health status in this cohort.

RESULTS

1,865 participants, aged 19-23 years, completed the Survey of Adult Transition and Health. Between 2001 and 2007, there was a 3.6 fold increase in the proportion experiencing delayed or forgone care; 10% reported a decline in health status. There was a 7.7-fold increase in the proportion reporting no insurance. In regression analysis, factors associated with declining health status between 2001 and 2007 included underlying disease severity and delayed or forgone care in young adulthood.

CONCLUSIONS

We found significant deterioration in insurance coverage, usual source of care and receiving timely health care as ASHCN aged into adulthood, and that this was associated with decline in health status. Our findings suggest that further population-based analyses of health outcomes are needed to plan for interventions to assist this vulnerable population.

Transition and sickle cell disease

Sickle cell disease (SCD), the most common genetic disease screened for in the newborn period, occurs in ~1 in 2400 newborns in the general population and 1 in 400 individuals of African descent in the United States. Despite the relative high prevalence and low pediatric mortality rate of SCD when compared with other genetic diseases or chronic diseases in pediatrics, few evidence-based guidelines have been developed to facilitate the transition from pediatrics to an internal medicine or family practice environment. As with any pediatric transition program, common educational, social, and health systems themes exist to prepare for the next phase of health care; however, unique features characterizing the experience of adolescents with SCD must also be addressed. These challenges include, but are not limited to, a higher proportion of SCD adolescents receiving public health insurance when compared with any other pediatric genetic or chronic diseases; the high proportion of overt strokes or silent cerebral infarcts (~30%) affecting cognition; risk of low high school graduation; and a high rate of comorbid disease, including asthma. Young adults with SCD are living longer; consequently, the importance of transitioning from a pediatric primary care provider to adult primary care physician has become a critical step in the health care management plan. We identify how the primary care physicians in tandem with the pediatric specialist can enhance transition interventions for children and adolescents with SCD.

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.

Social participation of adolescents with cerebral palsy: trade-offs and choices

This article reports on the findings of a qualitative study about the experiences and perceptions of adolescents with cerebral palsy (CP) in relation to social participation. A phenomenological approach was used to interview 10 adolescents with CP, 17 to 20 years of age, selected using purposeful sampling. An iterative process of data collection and analysis resulted in four themes about social participation. The themes of experience, barriers, and supports, and tradeoffs supported the current view of participation as a dynamic interaction between person and environment. The fourth theme of making choices described the unique challenges facing adolescents with CP in terms of deciding what was most important and meaningful to them now and in their future. Health care professionals can support adolescents as they develop the capacity to make their own decisions during the transition to adult living by ensuring that assessments and interventions address social participation.

Patient safety in the rehabilitation of children with spinal cord injuries, spina bifida, neuromuscular disorders, and amputations

Pediatric patient safety continues to challenge both pediatricians and pediatric physiatrists. While there is a trend toward developing general patient safety initiatives, there is little research on pediatric patient safety. This article identifies major areas of general safety risk, with a focus on timely diagnosis and care coordination to prevent secondary complications that compromise health, function, and quality of life in pediatric neuromuscular disease, spinal cord disorders, and amputation.

A social-ecological model of readiness for transition to adult-oriented care for adolescents and young adults with chronic health conditions

BACKGROUND

Policy and research related to transition to adult care for adolescents and young adults (AYAs) has focused primarily on patient age, disease skills and knowledge.

OBJECTIVE

In an effort to broaden conceptualization of transition and move beyond isolated patient variables, a new social-ecological model of AYA readiness for transition (SMART) was developed.

METHODS

SMART development was informed by related theories, literature, expert opinion and pilot data collection using a questionnaire developed to assess provider report of SMART components with 100 consecutive patients in a childhood cancer survivorship clinic.

RESULTS

The literature, expert opinion and pilot data collection support the relevance of SMART components and a social-ecological conceptualization of transition. Provider report revealed that many components, representing more than age, disease knowledge and skills, related to provider plans for transferring patients.

CONCLUSIONS

SMART consists of inter-related constructs of patients, parents and providers with emphasis on variables amenable to intervention. Results support SMART's broadened conceptualization of transition readiness and need for assessment of multiple stakeholders' perspectives of patient transition readiness. A companion measure of SMART, which will be able to be completed by patients, parents and providers, will be developed to target areas of intervention to facilitate optimal transition readiness. Similar research programmes to establish evidence-based transition measures and interventions are needed.

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.