SPN Position Statement: Transition of Pediatric Patients Into Adult Care

Interventions to support young adults and families with the healthcare transition between paediatric and adult nephrology health services: A systematic scoping review

BACKGROUND

Healthcare transition can be challenging for young people and families living with chronic kidney conditions, including those with rare renal disorders who often have multi-systemic conditions, those who have undergone kidney transplantation, and those who face intense treatments like dialysis. Comprehensive, holistic healthcare transition interventions are required, encompassing physical, psychosocial, sexual, educational and vocational support.

AIM

This manuscript presents a systematic scoping review synthesising the healthcare transition interventions to support youth and families within nephrology services.

METHODS

This review followed Arksey and O'Malley's five-stage framework, updated by Levac, Colquhoun and O'Brien and the Joanna Briggs Institute. Six databases were systematically searched: CINAHL Plus with Full Text, Embase, PsycINFO, Web of Science, PubMed, and the Applied Social Sciences Index and Abstracts (ASSIA), locating 12,662 records. Following a systematic screening process, 28 articles met the inclusion criteria. Results were analysed systematically and presented using the PAGER framework developed by Bradbury-Jones et al. (2022).

RESULTS

Various interventions were sourced. Three broad patterns emerged: 1. Contextual Factors, e.g. cultural differences between paediatric and adult services; 2. Major Intervention Components, e.g. parental/familial/peer-to-peer support, and 3. Personal factors, e.g., self-management ability.

CONCLUSION

Few interventions are available to support youth with rare renal disorders, specifically. Future research must be directed at this cohort. Healthcare transition timing remains hotly contested, with additional guidance required to support decision-making. Finally, limited interventions have been evaluated for practice.

IMPLICATIONS

This review has provided various considerations/recommendations that should be taken into account when designing, implementing or evaluating future healthcare transition supports.

Cliff or bridge: breaking up with the paediatric healthcare system

Transition from paediatric to adult healthcare is a normal part of the care trajectory, yet the process often leaves much to be desired. In this commentary, I share my family's journey of this care transition, particularly the handover aspect, by providing examples of different ways that relationships were ended by paediatric healthcare professionals. The ending of these relationships often felt like 'breaking up'. I also share an example of a supported handover, which bridged the transition from paediatric to adult care. To improve transitions, we need genuine acknowledgement of the paediatric medical trauma stress (PMTS) experienced by families such as mine following years of interactions in the healthcare system. Along with following transition checklists, patients and families need authentic and meaningful closure to longitudinal relationships and trauma-informed care practices as we move forward into the adult care system.

Improving the use of transition readiness measures in research and clinical care

Measurement of transition readiness is considered a crucial component of effective transition. It is included as one of the Six Core Elements of Transition in national transitional care guidelines. However, the current measures of transition readiness have not been found to correlate with either current or future health outcomes for youth. In addition, there are challenges in measuring transition readiness in youth with intellectual and developmental disabilities, who may not be expected to achieve skills and knowledge that are considered essential for transition in typically developing youth. These concerns make it difficult to know how best to use transition readiness measures in research and clinical care. This article highlights the appeal of measuring transition readiness in clinical and research contexts, the current barriers that prevent us from fully achieving those benefits, and potential strategies for bridging the gap. IMPACT: Transition readiness measures were developed as an attempt to identify those patients who were ready to successfully navigate the transition from pediatric to adult health care. Thus far, the measures that have been developed do not appear to be related to health outcomes such as disease control or timely attendance of the first adult appointment in adult care. We provide suggestions for how to address the current concerns with the available transition readiness measures.

Health care transition planning for adolescents and emerging adults with intellectual disabilities and developmental disabilities: Distinctions and challenges

PURPOSE

The purpose of this article is to provide the reader with insight and enhanced understanding of the health care transition planning process for adolescents and emerging adults with intellectual disabilities and developmental disabilities. There are distinctly different programmatic considerations that need to be addressed in advancing their transfer of care to adult providers and promoting their transition to adulthood. These differences are due in part to the federal and state legislative initiatives that were established in the education, rehabilitation, employment, and developmental disabilities service systems. In contrast, no comparable federal and state mandates exist in the system of health care. The legislative mandates in education, rehabilitation, and employment are presented and discussed as well as the federal legislation on rights and protections for individuals with intellectual disabilities and developmental disabilities. Consequently, health care transition (HCT) planning involves application of a framework of care that is characteristically different than the planning efforts undertaken for adolescents and emerging adults (AEA) with special health care needs (SHCN)/disabilities and for typically developing AEA. The best practice HCT recommendations are discussed in the context of this intellectual disabilities and developmental disabilities framework of care.

CONCLUSIONS

Health care transition planning for adolescents and emerging adults with intellectual disabilities and developmental disabilities involves additional and distinctly clinical and programmatic models of care.

PRACTICE IMPLICATIONS

Health care transition planning guidance for adolescents and emerging adults with intellectual disabilities and developmental disabilities are provided based upon best practice recommendations.

Health Care Transition Planning: Educational Needs of Pediatric Nurses and Pediatric Nurse Practitioners

INTRODUCTION

The purpose was to identify the educational needs of pediatric nurses and pediatric nurse practitioners providing direct care to transition-aged youth with chronic illness and disability and to identify strategies to develop health care transition planning (HCTP) expertise.

METHOD

Mixed-methods descriptive analyses were performed on survey data extracted from a larger national study exploring the provision of HCTP activities performed by nurses of two pediatric nursing professional organizations.

RESULTS

Items querying educational needs were completed by 1,162 pediatric nurses serving in advanced practice and staff roles. Twenty percent reported having specialized HCTP education. Of which more than half received it outside of the workplace. Factor analysis revealed two constructs explaining 73.4% of the variance in nurses' reported level of knowledge.

DISCUSSION

HCTP education and the development of nurse-led services to facilitate optimal health care transitions outcomes are necessitated. Academia and service have a shared responsibility in educating nurses.

Measuring health care transition: Across time and into the future

PROBLEM

Youth with special health care needs often experience significant difficulty transitioning into adult health care services and adult life. Services supporting youths' transition from pediatric to adult health care (Health Care Transition (HCT)) have been a priority for nearly 30 years to improve this transition process. The Health Resources and Service Administration, Maternal and Child Health Bureau have measured HCT service provision since 2001 but the longitudinal use of this measure has never been examined (Blumberg, 2003; Maternal and Child Health Bureau, n.d.).

ELIGIBILITY CRITERIA

This manuscript highlights the consistent and inconsistent uses of HCT constructs in two prominent national surveys (the National Survey of Children with Special Health Care Needs (NS-CSHCN) and the National Survey of Children's Health (NSCH)) between 2001 and 2019. All studies utilizing an HCT measure within a national survey between the 18 years were included in this examination.

RESULTS

Significant changes have been made to the measurement of HCT service provision resulting in inconsistencies over the last 18 years. Measurement criteria and survey questions have changed substantially from the NS-CSHCN and NSCH limiting one's ability to examine trends in HCT since 2001. Since 2016, few changes have been made, allowing for analysis of trends over time. Importantly, the NSCH includes added questions pertaining to HCT that are not included in the composite HCT outcome measure.

CONCLUSION

Future work should include a validation study of the HCT outcome in the National Survey of Children's Health and inclusion of additional HCT questions to promote continued and extensive use of a measure that more fully represents the needs of youth and their families.

Mediating effects of coping styles on the relationship between family resilience and self-care status of adolescents with epilepsy transitioning to adult healthcare: A cross-sectional study in China

PURPOSE

This study aimed to explore the relationship between family resilience, coping styles, and self-care among Chinese adolescents with epilepsy.

DESIGN AND METHODS

A total of 1238 adolescents with epilepsy in nine tertiary hospitals in China participated in a cross-sectional survey conducted from May 2018 to March 2020. Structural equation modeling was used to analyze the mediating effect.

RESULTS

The total scores for family resilience and coping styles were positively correlated with the total self-care status score of adolescents with epilepsy during their transition (r = 0.209, 0.202, P < 0.01). Family resilience was positively correlated with coping style (r = 0.450, P < 0.01). The modified model's fit index included χ²/df = 1.970, P = 0.001, RMSEA = 0.054, TLI = 0.973, CFI = 0.978, GFI = 0.941, AGFI = 0.917, NFI = 0.956, and IFI = 0.978. The confidence interval (CI) was 0.004-0.140 for the indirect effect and 0.033-0.306 for the direct effect.

CONCLUSIONS

The self-care status of adolescents with epilepsy during the transitional period is closely related to coping style and family resilience. Coping style mediates family resilience and self-care status.

PRACTICE IMPLICATIONS

Healthcare teams should pay attention to the coping ability of adolescents with epilepsy to help them transition smoothly and to improve family functioning. This study provides a theoretical basis for establishing transitional care programs for adolescents with chronic illnesses. The significant mediating effect of coping style should be emphasized in modalities of healthcare that include patient participation.

Long-Term Care of the Pediatric Kidney Transplant Recipient

Pediatric kidney transplant recipients are distinguished from adult recipients by the need for many decades of graft function, the potential effect of CKD on neurodevelopment, and the changing immune environment of a developing human. The entire life of an individual who receives a transplant as a child is colored by their status as a transplant recipient. Not only must these young recipients negotiate all of the usual challenges of emerging adulthood (transition from school to work, romantic relationships, achieving independence from parents), but they must learn to manage a life-threatening medical condition independently. Regardless of the age at transplantation, graft failure rates are higher during adolescence and young adulthood than at any other age. All pediatric transplant recipients must pass through this high-risk period. Factors contributing to the high graft failure rates in this period include poor adherence to treatment, potentially exacerbated by the transfer of care from pediatric- to adult-oriented care providers, and perhaps an increased potency of the immune response. We describe the characteristics of pediatric kidney transplant recipients, particularly those factors that may influence their care throughout their lives. We also discuss the risks associated with the transition from pediatric- to adult-oriented care and provide some suggestions to optimize the transition to adult-oriented transplant care and long-term outcomes.

Feasibility and use of a transition process planning and communication tool among multiple subspecialties within a pediatric health system

PURPOSE

An emerging need to improve health care transition planning has developed worldwide as more youth with special health care needs are surviving to adulthood. Nurses have been instrumental in facilitating transition planning and supporting youth throughout this process. While various transition tools have been developed, health professionals' utilization and perception of these tools have yet to be explored. Furthermore, there are no universally-accepted documentation tools for transition planning. The purpose of this study was to develop and implement a transition process planning and communication tool to facilitate transition planning among multiple, pediatric subspecialties within a system-wide transition program.

DESIGN AND METHODS

This project was a cross-sectional quality improvement initiative. Eligible encounters in the electronic medical record (N = 20,645) were obtained from 38 subspecialty clinics at a large, freestanding pediatric health system. Transition planning documentation was monitored for 8 months pre-implementation and 14 months post-implementation of the tool. Health professionals (N = 89) completed a survey to assess the tool's feasibility.

RESULTS

Implementation of the tool was feasible and corresponded with increased transition planning documentation post-implementation. Nurses represented 33% of the sample that utilized the tool. Survey results revealed barriers to documentation and utilization of the tool, along with strategies for improvement.

PRACTICE IMPLICATIONS

This study demonstrates that health professionals, especially pediatric nurses and nurse practitioners, are willing to adopt new, electronic documentation tools to enhance multidisciplinary transition planning consistent with best practices. Future studies should address identified barriers, assess the effectiveness of the tool on improving transition outcomes, and consider implications for integration into global health care models. System-wide implementation of such tools may improve multidisciplinary communication and coordination of care for youth with special health care needs.

Reflection on young adult transitional care in the Boston Children's Hospital Perioperative Care Coordination Clinic

THEORETICAL PRINCIPLES

The complexity of pediatric healthcare has increased due to advancement in research and identification of new treatment modalities. With these advancements, life expectancy has increased creating a greater need for young adult transition into adult medical settings and specialty care (Marani et al., 2020). The holistic approach of nursing care is essential in assisting young adults during this transitional period.

PHENOMENON ADDRESSED

Many pediatric hospitals and subspecialties continue to care for young adults ≥18 years of age that have not transitioned to adult care. In the perioperative care coordination clinic at Boston Children's Hospital, pediatric nurses and advanced practice nurse practitioners provide care to patients from infancy to adulthood, throughout many specialties, to ensure safe perioperative care for a medically complex surgical population. The purpose of this paper is to describe the PCCC young adult care coordination process that provides engaging opportunities for the young adult to advocate for oneself and promote autonomy as they proceed through the stages of transition to adult care.

RESEARCH LINKAGES

The perioperative care coordination process at Boston Children's Hospital aligns with the Society of Pediatric Nurses position statement that recommended pediatric nurses utilize a framework (Betz, 2017) and Meleis' middle-range theory of Transitions that identified the nursing role during the transitional process (Meleis et al., 2000). A suggestion for future nursing research includes development of a nursing framework that nurses can utilize when supporting young adults during their progression through the steps of transition from pediatric to adult perioperative programs.

Exploratory study of the provision of academic and health-related accommodations to transition-age adolescents and emerging adults with spina bifida

PURPOSE

The purpose of this exploratory study was to investigate the types of academic and health-related accommodations provided to adolescents and emerging adults with spina bifida aged 9-20 years.

METHODS

Data were extracted from the paper and electronic records of transition-age youth enrolled in the study. Four open ended items involved content analysis.

RESULTS

The most frequently identified accommodation was enrollment in special education classes in 47.7% of the charts. Other academic accommodations that were most often reported were adaptive physical education (n = 71, 39.9%), tutoring (n = 28; 15.7%), and home schooling (n = 21; 11.8%). Clean intermittent catheterization was the most frequently identified health-related accommodation provided by the school nurse/aide (n = 57; 32%).The largest percentage of requests for additional accommodations were made during the middle school grades (15; 54.8%) followed by high school (10; 32.2%).

CONCLUSION

Findings demonstrated that persistent issues were identified by parents/adolescents regarding the provision of school-related accommodations. This is a relevant area for clinical practice to ensure students with special health care needs and those with spina bifida receive the academic and health-related accommodations in their Individualized Education Program/504 plans.

Prevalence and barriers to health care transition for adolescent patients with childhood-onset chronic diseases across Japan: A nation-wide cross-sectional survey

Since the Japan Pediatric Society published its "Recommendations on Transitional Care for Patients with Childhood-Onset Chronic Diseases" in 2014, there has been an increased interest in the health care transition of adolescents with childhood-onset chronic diseases in Japan. However, the actual status of healthcare transition was not studied yet. The purpose of this study was to explore the prevalence of transitional support for adolescent patients with childhood-onset chronic disease and the factors hindering their transition. We conducted an anonymous questionnaire survey in August 2020, targeting physicians and nurses involved in health care transition at 494 pediatric facilities in Japan. Survey items included demographic data, health care systems related to transition to adult departments, health care transition programs based on Six Core Elements (establishing transition policy, tracking and monitoring transition progress, assessing patient readiness for transition, developing the transition plan with a medical summary, transferring the patient, completing the transfer/following up with the patient and family), barriers to transition (34-item, 4-point Likert scale), and expectations in supporting transition (multiple-choice responses), which consisted of five items (78 questions); all questions were structured. Descriptive statistics were used for analysis. Of the 225 responses collected (45.5% response rate), 88.0% were from pediatricians. More than 80% of respondents transferred patients of 20 years or older, but only about 15% had took a structured transition process of four or more based on the Six Core Elements. The top transition barriers were "intellectual disability/rare disease" and "dependence on pediatrics" as patient/family factors, and "lack of collaboration with adult healthcare (relationship, manpower/system, knowledge/understanding)" as medical/infrastructure factors. The study provides future considerations, including the promotion of structured health care transition programs, development of transitional support tailored to the characteristics of rare diseases and disorders, and establishment of a support system with adult departments.

Transfer of Care for People with Severe Forms of Thalassemia: Learning from Past Experiences to Create a Transition Plan

PURPOSE

To demonstrate the need for developing standardized healthcare transition plans for persons with severe forms of thalassemia as life expectancy continues to improve.

DESIGN AND METHODS

This study utilized an original questionnaire to explore the factors that determined whether individuals residing in North America transferred their thalassemia care from a pediatric to an adult specialist, and what components they believed should be included in a healthcare transition plan.

RESULTS

Approximately one-third of respondents remained under the care of a pediatric hematologist, most commonly citing the thalassemia knowledge of the specialist as their reason for not transferring their care. Additionally, this group also reported more thalassemia-related services available at their healthcare facility, better access to flexible hours for blood transfusions and increased satisfaction with their care. Adults with thalassemia recommend enhanced communication between patient and provider and building opportunities for patients to assume the role of self advocate as key components for a healthcare transition plan.

CONCLUSIONS

There is an inconsistency in the transfer-of-care experience of adults with severe forms of thalassemia living in North America. Development of a healthcare transition program would benefit from the input of those who have gone through this process.

PRACTICE IMPLICATIONS

A well informed healthcare transition program can enhance the quality of life of those with thalassemia. The training and educational background of nurses and genetic counselors make them uniquely qualified to guide patients on how to advocate for themselves and to ensure continuity of care during a healthcare transition.

Survey of US pediatric nurses' role in health care transition planning: Focus on assessment of self-management abilities of youth and young adults with long-term conditions

The survival rates of youth and young adults (YYAs) diagnosed with long-term conditions have improved considerably as 90% now enter adulthood; health care transition planning (HCTP) has emerged as a nursing practice priority. The aim of this national online survey was to investigate the extent to which nurses, recruited from two major United States pediatric nursing organizations are involved with HCTP including assessing YYA self-management abilities (SMA). Findings of a 9-item assessment of self-management abilities subscale of the nurses' role in HTCP tool are reported. The nurse respondents (n = 1269), identified the most frequently assessed SMA was the YYAs' ability to understand and speak about their condition and its treatment (M = 2.3, SD = .89). The least frequently assessed was the YYAs' ability to identify community advocates to help them become more independent (M =1.5, SD = .90). Regression analysis identified significant predictors of the frequency nurses assess YYA for SMA included nurses' level of knowledge, perceived level of importance, HCTP and skills identified in job description, and caring for YYA. Findings indicate HCTP care advancements will necessitate HCTP training and development of nurse-led service efforts to facilitate optimal outcomes for YYA.

A Typology of Transition Readiness for Adolescents with Congenital Heart Disease in Preparation for Transfer from Pediatric to Adult Care

PURPOSE

To understand the effectiveness of a nurse-led transition intervention by analyzing qualitative data generated in the context of a clinical trial.

DESIGN & METHODS

Qualitative study of a two-session transition intervention conducted by registered nurses at two sites. Adolescents aged 16-17 years with moderate or complex congenital heart disease (CHD) had been randomized to a two-session transition intervention or usual care. Session 1 emphasized patient education including creation of a health passport and goal setting. Session 2, two months later, emphasized self-management. Qualitative data extracted from intervention logs, field notes and audio recordings of the sessions were analyzed for content and themes.

RESULTS

Data from 111 transition intervention sessions with 57 adolescents were analyzed. Creating a health passport, goal setting, and role-plays were the elements of the intervention most valued by participants. A typology of transition readiness was identified: 1) the independent adolescent (5%), already managing their own care; 2) the ready adolescent who was prepared for transition after completing the intervention (46%); 3) the follow-up needed adolescent who was still in need of extra coaching (26%), and 4) the at-risk adolescent who warranted immediate follow-up (14%). Baseline knowledge and transition surveys scores validated the typology.

CONCLUSIONS

A two-session nursing intervention met the transition needs of approximately half of adolescents with CHD. However, additional transition-focused care was needed by 40% of participants (groups 3 and 4).

PRACTICE IMPLICATIONS

These findings will guide pediatric nurses and other healthcare professionals to optimize an individualized approach for ensuring transition readiness for adolescents with CHD.

Self-management for youth and young adults with special health needs: protocol for a scoping review of health care transition planning literature

OBJECTIVE

The purpose of this scoping review is to explore the extent to which self-management of youth and young adults with special health care needs is reported in the health care transition literature.

INTRODUCTION

It is essential for youth and young adults with special health care needs to learn the self-management skills, to the extent possible, that are essential in maintaining the stability of their chronic condition to seamlessly transfer to adult care and live independently. Acquisition of self-management competencies for chronic care management is an essential component of health care transition preparation.

INCLUSION CRITERIA

The inclusion criteria will be based upon age and condition designation. The age range of participants will include youth and young adults, aged nine to 35 years, who have special health care needs. Inclusion criteria consists of both non-categorical and diagnostic specific terminology for youth and young adults with a childhood acquired chronic condition. Non-categorical terms used include "long-term chronic condition," "special health care needs," "medical complex condition," "complex care needs," "developmental disability," "intellectual disability," "mental health condition," "emotional disabilities," "physical disabilities," "chronic illness," and "chronic condition."

METHODS

The following databases will be accessed for this health care transition scoping review: CINAHL, Cochrane CENTRAL, Embase, Ovid MEDLINE, PsycINFO, and Web of Science. Relevant gray literature will be accessed as well. The Covidence software platform will be used to review citations and full-text articles. Two reviewers will independently review abstracts and full texts of studies, and extract data using the data extraction tool. Any conflicts will be resolved with a third reviewer. Review findings will be presented in tabular format and narrative synthesis based upon the scoping review objective.

Validation of the RAISE (Readiness Assessment of Independence for Specialty Encounters) Tool: Provider-Based Transition Evaluation

PURPOSE

The aim of this study was to establish content validity of a developmentally based assessment tool of readiness for medical independence for specialty providers.

DESIGN AND METHODS

The validation process used expert panel evaluation to assess the items believed to measure the desired content in the nine age-based scales within the RAISE (Readiness Assessment of Independence for Specialty Encounters) tool. Experts in child development and transition rated items on relevance, clarity and developmental appropriateness via electronic survey. Statistical analyses included calculation of interrater agreement (IRA), content validity indices (CVIs), and factorial validity indices (FVI).

RESULTS

A total of 135 items were rated by 36 experts. Mean I-CVIs for 123 items across nine developmental scales met criteria for retention, ranging from 0.76 (threshold) to 1.00 (excellent). Mean I-CVIs for all 25 items across the five psychosocial stressor scales met criteria for retention, ranging from 0.92 to 1.00 (excellent).

CONCLUSIONS

Findings from the current content validation study suggest that items on the revised RAISE tool are relevant, clear, and developmentally-appropriate as rated by experts in the fields of child development and transition. The tool, consisting of age based scales (ages birth-2, 3-4, 5-6, 7-8, 9-11, 12-13, 14-15, 16-17, 18-21), is shown to have content validity of the retained items meeting criteria.

PRACTICE IMPLICATIONS

With content validity of the RAISE tool established by experts, this developmentally based assessment tool can be integrated into practice to assist providers in educating patients around skills of medical independence which could improve transition outcomes.

Understanding the Phenomenon of Health Care Transition: Theoretical Underpinnings, Exemplars of Nursing Contributions, and Research Implications

This manuscript features exemplars of nursing science that contribute to the development of health care transition practice models and evidence-based care. These research exemplars demonstrate the need for diverse investigative approaches coupled with clinical acumen and expertise in health care transition. The focus of describing nurse-led and nurse-contributory research and quality improvement efforts in this emerging field is offered to foster nursing involvement.Also, research efforts are not limited to the pediatric populations; research is needed for the provision of evidence-based careand monitoring of health and psychosocial outcomes of adults with childhood acquired chronic conditions.

Implementing Pediatric Transition Education Initiative During Inpatient Admissions in the Epilepsy Monitoring Unit

BACKGROUND

Adolescents with epilepsy are a population with unique needs when addressing transition to adult care. Scheduled, non-emergent admissions to the Epilepsy Monitoring Unit (EMU) have not yet been utilized to improve transition education.

METHODS

The overarching goal of this evidence-based practice project was to explore opportunities to enhance the transition education patients and families receive in the clinic setting by leveraging scheduled inpatient admissions for EEG monitoring to provide structured transition education. Twenty-one Neurology Clinic providers were surveyed about their perspectives on the transition process. Thirty-five adolescent patients (12-20 years old) received a pre-test regarding their condition, health maintenance and disease management, and a subsequent post-test measuring knowledge retention after education with a provider. Documentation in the electronic health record (EHR) using an institution created transition flowsheet and a standardized template was used to communicate through the EHR with the primary neurology team.

FINDINGS

The effectiveness of the intervention was supported as 100% of patients demonstrated increased knowledge after transition education. Providers' knowledge and support of transition efforts increased regarding tools and guidelines for transition of adolescents to adult care.

DISCUSSION

These results support the feasibility of providing transition education in the EMU with shared responsibility between inpatient and ambulatory providers.

IMPLICATIONS FOR PRACTICE

Improved use of the transition flowsheet in the EMU and by ambulatory setting providers will enhance the process of transition. Discussion of self-management with adolescent patients during all phases of health care will encourage independence and promote successful transition to adult health care.

The Transition to Adult Health Care in Youth With Spina Bifida: Theory, Measurement, and Interventions

PURPOSE

This article focuses on the transition to adult health care in youth with spina bifida (SB) from the perspective of theory, measurement, and interventions.

METHODS

The purpose of this article is to discuss (a) a theory of linkages between the transfer of medical responsibility from parent to child and the transition from pediatric to adult health care, as mediated by transition readiness; (b) measurement issues in the study of self-management and the transition to adult health care; and (c) U.S.-based and international interventions focused on the transition to adult health care in young adults with SB.

FINDINGS

Individuals with SB must adhere to a complex multicomponent treatment regimen while at the same time managing a unique array of cognitive and psychosocial challenges and comorbidities that hinder self-management, medical adherence, and the transition to adult health care. Moreover, such youth endure multiple transitions to adult health care (e.g., in the areas of urology, orthopedics, neurosurgery, and primary care) that may unfold across different time frames. Finally, three transition-related constructs need to be assessed, namely, transition readiness, transition completion, and transition success.

CONCLUSIONS

SB provides an important exemplar that highlights the complexities of conducting research on the transition to adult health care in youth with chronic health conditions. Many transition trajectories are possible, depending on the functioning level of the child and a host of other factors. Also, no single transition pathway is optimal for all patients with SB.

CLINICAL RELEVANCE

The success of the process by which a child with SB transitions from pediatric to adult health care can have life-sustaining implications for the patient.

Youths' Experiences of Transition from Pediatric to Adult Care: An Updated Qualitative Metasynthesis

PROBLEM

Improvements in chronic disease management has led to increasing numbers of youth transitioning to adult healthcare. Poor transition can lead to high risks of morbidity and mortality. Understanding adolescents and young adults (AYA) perspectives on transition is essential to developing effective transition preparation. The aim of this metasynthesis was to synthesize qualitative studies assessing the experiences and expectations of transition to adult healthcare settings in AYAs with chronic diseases to update work completed in a prior metasynthesis by Fegran, Hall, Uhrenfeldt, Aagaard, and Ludvigsen (2014).

ELIGIBILITY CRITERIA

A search of PubMed, Medline, PsycINFO, and CINAHL was conducted to gather articles published after February 2011 through June 2019.

SAMPLE

Of 889 articles screened, a total of 33 articles were included in the final analysis.

RESULTS

Seven main themes were found: developing transition readiness, conceiving expectations based upon pediatric healthcare, transitioning leads to an evolving parent role, transitioning leads to an evolving youth role, identifying barriers, lacking transition readiness, and recommendations for improvements.

CONCLUSIONS

Findings of this metasynthesis reaffirmed previous findings. AYAs continue to report deficiencies in meeting the Got Transition® Six Core Elements. The findings highlighted the need to create AYA-centered transition preparation which incorporate support for parents.

IMPLICATIONS

Improvements in transition preparation interventions need to address deficiencies in meeting the Got Transition® Six Core Elements. More research is needed to identify and address barriers implementing the transition process.

Moving on: How to switch young people with chronic intestinal failure from pediatric to adult care. a position statement by italian society of gastroenterology and hepatology and nutrition (SIGENP) and italian society of artificial nutrition and metabolism (SINPE)

In 2019 the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) and the Italian Society of Artificial Nutrition and Metabolism (SINPE) created a joint panel of experts with the aim of preparing an official statement on transition in Chronic Intestinal Failure (CIF). The transition from pediatric to adult care has a key role in managing all chronic diseases and in optimizing the compliance to care. Thus SIGENP and SINPE, in light of the growing number of patients with IF who need long-term Parenteral Nutrition (PN) and multidisciplinary rehabilitation programs throughout adulthood, shared a common protocol to provide an accurate and timely process of transition from pediatric to adult centers for CIF. The main objectives of the transition process for CIF can be summarized as the so-called "acronym of the 5 M": 1)Motivate independent choices which are characteristics of the adult world; 2)Move towards adult goals (e.g. self-management of his pathology and sexual issues); 3)Maintain the habitual mode of care; 4) Minimize the difficulties involved in the transition process and 5)Modulate the length of the transition so as to fully share with the adult's team the children's peculiarities.

Cardiovascular Risk and Cardiovascular Health Behaviours in the Transition From Childhood to Adulthood

The prevention and management of cardiovascular risk factors during the transition from childhood to adulthood is critically important in defining cardiovascular health trajectories. Unfortunately, many young people fall out of clinical care during this important time, leading to worsening cardiovascular risk and missed opportunities to modify future outcomes. The field of health care transition has evolved to support young people with complex health needs in developing self-management and self-advocacy skills to promote positive health outcomes despite changes in health care providers and resources. While transitional care efforts are largely focused on childhood-onset chronic illnesses such as sickle cell disease and cystic fibrosis, young people with cardiovascular risk factors such as hypertension, obesity, and dyslipidemia also stand to benefit from structured supports to ensure continuity in care and positive health behaviours. On the backdrop of the broader health care transition literature, we offer practical insights and suggestions for ensuring that young people with cardiovascular risk factors experience uninterrupted high-quality care and support as they enter the adult health care system. Starting transition preparation in early adolescence, actively engaging all key stakeholders throughout the process, and remaining mindful of the developmental underpinnings and social context of transition are keys to success.

Empowering Young Persons with Congenital Heart Disease: Using Intervention Mapping to Develop a Transition Program - The STEPSTONES Project

PURPOSE

Describe the implementation of intervention mapping in the development of a transition program that aims to empower adolescents with congenital heart disease.

DESIGN AND METHODS

To gain a better understanding of the problem, we conducted a literature review, focus group and individual interviews, and a cross-sectional survey. This information helped us decide on the scope of the intervention, relevant theories, determinants, formulate performance and change objectives and identify adequate evidence-based change methods. Once the transition program had been designed, effectiveness and process evaluation studies were planned.

RESULTS

Young persons with congenital heart disease have insufficient disease-related knowledge, self-management skills and high parental involvement. The transition program involves three meetings with a trained transition coordinator over a two-and-a-half-year period and targets young persons with congenital heart disease and their parents. The transition coordinators use change techniques such as goal-setting, modeling and active learning in order to target three personal determinants (knowledge, self-efficacy and self-management).

CONCLUSIONS

The use of intervention mapping may lead to designing interventions tailored to the needs of the targeted population. The transition program described in this paper is currently being evaluated in a hybrid experimental design with simultaneous undertaking of the process evaluation.

PRACTICE IMPLICATIONS

This transition program can lead to the empowerment of young persons with congenital heart disease and help them in the process of becoming more responsible for their care. If proven effective, it can be implemented for other chronic conditions.

Pediatric Nurses' Role in Health Care Transition Planning: National Survey Findings and Practice Implications

PURPOSE

Youth and young adults (YYA) with chronic illness and/or disability (CID) face numerous challenges in transition from pediatric to adult health care. Established evidence supports interdisciplinary team approaches to preparing youth and families for transition and transfer. The purpose of this national survey was to address a gap in current knowledge specific to pediatric nursing professionals' roles and responsibilities in health care transition planning (HCTP).

METHODOLOGY

A quantitative descriptive study using a survey questionnaire validated by experts in the field investigated respondents' role in HCTP, inclusion of HCTP in job description, levels of HCTP knowledge, and ratings of importance of HCTP elements. A volunteer sample of 1814 respondents was drawn from two professional organizations.

RESULTS

Over 64% of respondents performed HCTP activities related to complex chronic illness management. Only 18% reported specialized training in HCTP. The highest-ranking items in regard to perceived importance were educating and supporting disease self-management and speaking with families about complex needs. Predictors of perceived importance were role, inclusion of transition planning in a job description, percentage of time in direct care, caring for those aged 14 years and older, and level of knowledge about HCTP.

CONCLUSIONS

The findings highlight key aspects of the pediatric nurse role in HCTP and identify specific elements that can be addressed to support future HCTP role development.

PRACTICE IMPLICATIONS

Pediatric nurses perform a vital role in HCTP for YYA with CID that may be enhanced with the inclusion of HCTP activities in job descriptions and specialized interdisciplinary HCTP training related to this emerging and growing population.

Healthcare transition for adolescents and young adults with long-term conditions: Qualitative study of patients, parents and healthcare professionals' experiences

AIM AND OBJECTIVES

To examine the needs and perspectives regarding healthcare transition for adolescents and young adults (AYAs) with the following long-term conditions: diabetes, cystic fibrosis and congenital heart disease.

BACKGROUND

Transition of AYAs within healthcare services has become increasingly important as more children are surviving into adulthood with long-term conditions. Yet, limited empirical evidence exists regarding transition experiences.

DESIGN

Qualitative study fulfilling the completed consolidated criteria for reporting qualitative studies criteria (see Appendix S1).

METHODS

Semi-structured interviews with AYAs aged 14-25 years (n = 47), parents (n = 37) and health professionals (n = 32), which was part of a larger mixed-methods study. Sample was recruited from two children's hospitals and four general hospitals in Ireland.

RESULTS

Transfer occurred between the ages of 16-early 20s years depending on the service. None of the hospitals had a transition policy, and transition practices varied considerably. Adolescents worried about facing the unknown, communicating and trusting new staff and self-management. The transition process was smooth for some young adults, while others experienced a very abrupt transfer. Parents desired greater involvement in the transition process with some perceiving a lack of recognition of the importance of their role. In paediatric services, nurses reported following-up adolescents who struggled with treatment adherence and clinic attendance, whereas after transfer, little effort was made to engage young adults if there were lapses in care, as this was generally considered the young adults' prerogative.

CONCLUSIONS

The amount of preparation and the degree to which the shift in responsibility had occurred prior to transition appeared to influence successful transition for AYAs and their parents.

RELEVANCE TO CLINICAL PRACTICE

Nurses in collaboration with the multidisciplinary team can help AYAs develop their self-management skills and guide parents on how to relinquish responsibility gradually prior to transition.

Teaching Adolescents to Manage Their Own Health Care

Many factors impact an adolescent's willingness to appropriately use health-care services and intent to begin the health-care transition process. Published literature continues to show that the way adolescents experience and utilize health-care services is ineffective and has long-term impacts on individuals and systems. Building upon the success of an existing peer-to-peer workshop, a Toolkit was created to provide school-based health professionals the information and resources needed to deliver pertinent information to high school students in one lesson. Of 416 students, over two thirds reported that they plan to be more involved in their health care (69.8%), advocate for themselves in health-care settings (68.0%), talk openly and honestly with health-care providers (71.9%), and learn more about managing their own health care (68.6%). Integrating this information into existing health curricula provided a broader reach with minimal work and promising results that could improve overall health-care transition efforts.

Health Care Transition for Adolescent and Young Adults with Intellectual Disability: Views from the Parents

PURPOSE

This study explored the health care transition (HCT) experiences of parents of adolescents and young adults (AYAs) with intellectual disability (ID), 18-33 years of age, including barriers and facilitators to the AYA's transition to adulthood within and between the medical, educational, community, and vocational systems.

DESIGN AND METHODS

A qualitative descriptive design with semi-structured individual interviews with 16 parent participants was used. Purposive sampling of parents was utilized with variation on race/ethnicity and AYA age, stage in transition, and condition. This study was conducted through a major medical center in the southeast United States. Content analysis was utilized.

RESULTS

Three overarching themes represented the factors and essence of supporting AYAs with ID transition to adulthood. Inefficient and siloed systems illuminated barriers families are commonly experiencing within and between the medical, educational, community, and vocational systems. 'Left out here floundering' in adulthood, described the continued inadequacy of resources within each of these systems and parent's having to find available resources themselves. Hope despite uncertainty, included the perceived costs and benefits of their AYA's disability and the value of parent peer support in providing key knowledge of resources, strategies, and perspectives.

CONCLUSIONS

Our findings illuminate the need for improved infrastructure to provide effective HCT and partnerships to help integrate HCT support within other life course systems. Results support the rationale for non-categorical HCT-focused approach.

PRACTICE IMPLICATIONS

A parent peer coach-facilitated intervention offers promise for bridging the gap between systems and meeting family needs.

The Role of Grit in Health Care Management Skills and Health-related Quality of Life in College Students with Chronic Medical Conditions

PURPOSE

Adolescents and young adults (AYAs) with chronic medical conditions are at risk for reduced health-related quality of life (HRQoL). Recent research on AYAs without chronic medical conditions found that greater health care management skills were related to higher HRQoL. In addition, grit, an intrapersonal strength, has been linked to greater health care management skills and HRQoL. The current study extended these findings to AYAs with a chronic medical condition.

DESIGN AND METHODS

Three hundred and seventy-five undergraduates with a chronic medical condition completed questionnaires, including the short Grit Scale, Transition Readiness Assessment Questionnaire, and RAND 36-Item Short Form Survey.

RESULTS

Path analysis revealed a significant direct effect of grit on health care management skills and on both mental and physical HRQoL. Further, health care management skills had a significant indirect effect on the grit → mental HRQoL association, but not on the grit → physical HRQoL association.

CONCLUSIONS

Higher levels of grit were linked to better health care management skills and better mental and physical HRQoL. Further, grit and mental HRQoL were indirectly linked through health care management skills, suggesting the utility of these skills in improving mental HRQoL.

PRACTICE IMPLICATIONS

Given the observed benefits of higher grit and health care management skills on emotional HRQoL, and the potential impact of health care management skills on future physical HRQoL, interventions targeting the enhancement of grit and health care management skills may be beneficial in improving the efficacy of transition readiness interventions.

Gathering expert opinion to inform benchmarks to support transitional care

This study aimed to (1) explore views of known experts leading on transition, (2) gather insights on the essential features of transitional care models and (3) highlight opportunities for and barriers to change: to inform core elements of benchmarks for transitional care. We held three workshops ( n = 20) and used a telephone interview ( n = 1) with health and social care professionals with expertise working with young people with a range of health conditions and disabilities. The workshops included individual brainstorming and group discussion. Data were analysed using qualitative content analysis. The general consensus from stakeholders' discussions about transition was that 'things have become stuck'. Themes included: professionals' attitudes towards and knowledge about young people and transition, organizational barriers and 'lack of joined-up thinking' between services. Our work offers further insight into experts' perceptions of transition services within the United Kingdom. It is clear that there is still much to be done to improve transition, to better meet the needs of young people and parents and begin to offer equitable access to transitional care programmes. The benchmarks offer a starting point for professionals seeking to improve transition through enabling the identification of gaps in services and providing a platform to share successful practice initiatives.

An exploratory study of adolescents and emerging adults with spina bifida knowledge of their individual education program: Implications for health care transition planning

PURPOSE

The purpose of this study was to explore adolescents and emerging adults (AEA) with spina bifida (SB) understanding of their Individualized Education Program (IEP) and to identify factors related to their knowledge about their own IEP.

METHODS

Data were collected from January 2015 to July 2016 from 79 adolescents with SB. A ten-item questionnaire including demographics and questions specifically addressing IEPs was used. Qualitative analysis followed an iterative, emergent approach. Two experienced coders independently read and coded each of the three open-ended questions. It was determined that the responses of all three questions could feasibly be merged as the analysis of responses were similar.

FINDINGS

This was a predominately 70 (88.7%) Hispanic sample of AEA with SB who ranged in age from 12 to 20 years (M= 15.3 years) consisting of 41 males and 38 females. All reported they have/had an IEP. Four major themes and eleven subthemes emerged from the analysis. Major themes were: The Barometer of How I Am Doing, Creating the Right Match for Learning, Obtaining the Assistance I Need, and Future Goals and Planning.

CONCLUSIONS

Findings of this study reveal the IEP knowledge gaps and lack of lifestyle self-management skills AEA with SB reported pertaining to IEPs.

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

Risk and vulnerability encompass many dimensions of the transition from adolescence to adulthood. Transition from pediatric, parent-supervised health care to more independent, patient-centered adult health care is no exception. The tenets and algorithm of the original 2011 clinical report, "Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home," are unchanged. This updated clinical report provides more practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults. It also includes new and updated sections on definition and guiding principles, the status of health care transition preparation among youth, barriers, outcome evidence, recommended health care transition processes and implementation strategies using quality improvement methods, special populations, education and training in pediatric onset conditions, and payment options. The clinical report also includes new recommendations pertaining to infrastructure, education and training, payment, and research.

The Development and Content Validation of a Self-reported Instrument to Explore the Nurse's Role in Healthcare Transition Planning for Youth and Young Adults With Chronic Illness and/or Disability (NR-HCTP)

PURPOSE

To develop an instrument to assess the nurse's role and responsibilities in healthcare transition planning (HCTP) for youth and young adults (YYA) with chronic illness and/or disability (CI/D) that will determine to what extent nurses are involved with providing HCTP services; and identify the specific activities that nurses engage in when providing HCTP services.

DESIGN AND METHODS

A panel of seven experts in the field were used to determine content validity.

RESULTS

The final NR-HCTP instrument contains a total of 68 items (17 main items, 5 containing sub items) representing activities that nurses engage in when providing HCTP services, their level and extent of involvement, and their level of knowledge in the areas of HCTP.

PRACTICE IMPLICATIONS

An exploration of nurse's roles in HCTP for YYA with CI/D allows for discussion of current nursing practices in the transition process. The information obtained may be used to identify gaps in knowledge and practice guidelines, develop nursing core elements and educational materials to support nurses in their role, and inform nursing administrators in the development of appropriate HCTP position descriptions.

Methodologic Considerations for Transition Research Using the National Survey of Children with Special Health Care Needs: A Systematic Review of the Literature

The purpose of this review was to describe methodologic considerations in using the National Survey of Children With Special Health Care Needs (NS-CSHCN) for transition research in terms of variable inclusion and definition of transition outcomes and to provide suggestions for using NS-CSHCN for transition research. A systematic review was conducted. Inclusion criteria included use of NS-CSHCN data and transition as an outcome variable. Fourteen studies were included. Ten (71%) studies evaluated a sample of all CSHCN. Ten (71%) articles used all four variables recommended by the Maternal and Child Health Bureau core outcome on transition. Other variables included patient-centered medical home. The NS-CSHCN provides a rich dataset that can be used in transition research addressing transition preparation from the parent perspective. Using the NS-CSHCN, we recommend analyzing all variables related to the Maternal and Child Health Bureau core outcome for transition, variables related to patient-centered medical home, and further analysis of specific health conditions.

Pediatric Nurse Practitioners' Perspectives on Health Care Transition From Pediatric to Adult Care

INTRODUCTION

This study examined the perspectives of pediatric nurse practitioners (PNPs) regarding the needs of adolescents, parents/caregivers, clinicians, and institutions in the health care transition (HCT) process for adolescents/young adults.

METHODS

PNPs (N = 170) participated in a luncheon for those interested in transition at an annual conference. Small groups discussed and recorded their perspectives related to health care transition from adolescent to adult services. Content analysis was used to analyze responses (Krippendorff, 2013).

RESULTS

Four themes, Education, Health care system, Support, and Communication, emerged from the data analysis. PNPs identified health care informatics and adolescents' use of technology as additional critical aspects to be considered in health care transition.

DISCUSSION

Opportunities and challenges identified by the PNPs are discussed to improve the quality and process of transitioning adolescents to adult services. This report will help National Association of Pediatric Nurse Practitioners formulate a new Health Care Transition Policy Statement for the organization.

Descriptive Analysis and Profile of Health Care Transition Services Provided to Adolescents and Emerging Adults in the Movin' On Up Health Care Transition Program

Global efforts are underway to develop, implement and test health care transition (HCT) models of care. Most studies have focused on the transfer of care models. In contrast, the nurse-led interdisciplinary HCT model, Movin' On Up, provides comprehensive HCT services beginning in early adolescence. A retrospective analysis was conducted of data extracted from HCT records of 146 adolescents and emerging adults with spina bifida (with a mean age of 13.91 years) who were provided services in the Movin' On Up HCT program. Data were categorized based on the Health Care Transition Research Consortium HCT model and the Omaha System framework and as to type of direct HCT services provided by the HCT Specialist and nurse-led interdisciplinary team conferences conducted. Findings revealed that the scope of services provided represented the scope of comprehensive needs beyond those associated with the transfer of care.

Patient Perspectives on Nurse-led Consultations Within a Pilot Structured Transition Program for Young Adults Moving From an Academic Tertiary Setting to Community-based Type 1 Diabetes Care

PURPOSE

We aimed to evaluate patient self-management activities, patient perceptions of the therapeutic relationship and satisfaction with nurse-led consultations as part of a structured, pilot program transitioning young adults with type 1 diabetes (T1DM) to adult-oriented community-based practices.

DESIGN AND METHODS

A descriptive, cross-sectional study of patients receiving nurse-led consultations. Patients provided sociodemographic/health information, glycated hemoglobin (HbA1c) measures and completed questionnaires assessing self-management (Revised Self-Care Inventory) and the therapeutic relationship (Caring Nurse-Patient Interaction - short scale). HbA1c values were compared to guideline recommendations.

RESULTS

Twenty patients participated. HbA1c was ≤7.5% in 3/14 (21%) and 5/14 (36%) exhibited poor glycemic control (≥9.5%). The greatest concordance for self-care was in relation to insulin therapy (4.5±0.5) while patients reported the lowest adherence to diet recommendations (2.9±0.8). Overall satisfaction with nurse-led consultations was high (4±0.5 out of 5). Patients considered diabetes knowledge and technical competence as very important and were most pleased with the humanistic aspects of nursing care. Respect for privacy was deemed the most important (and most frequently observed) nursing attitude/behavior during consultations.

CONCLUSIONS

Young adults found the nurse-led consultations with therapeutic education to develop T1DM self-care skills are an important complement to medical management during transition.

PRACTICE IMPLICATIONS

Patient autonomy and privacy should be respected during this developmental period. Nurses taking a humanistic approach towards accompanying and supporting the patient can enhance the therapeutic relationship during transition and promote continuity of care. Transition nurses can use technical competence and therapeutic education to empower patients for self-management.

Self-management and health care transition: Trials, tribulations and triumphs

PURPOSE

The purpose of this article is to provide perspectives pertaining to the importance of fostering comprehensive self-management competencies of AEA-SHCN, with attention directed to AEA with spina bifida based upon the Health Care Transition Research Consortium Health Care Transition model. This article is based upon the plenary presentation given at the Spina Bifida 3rd World Congress, entitled, Self-Management and Health Care Transition: Trials, Tribulations and Triumphs.

METHOD

A historical perspective of healthcare transition initiatives and best practice guidelines is provided that have influenced the field of research and practice. Relatively scant attention has been directed to the development and refinement of self-management competencies prior to the transfer of care and transition to adulthood. Against this backdrop of the predominant framework of care focused on the transfer of care, a discussion of our team's experience with the provision of healthcare transition services and the complexity of addressing the self-management needs of the adolescents and emerging adults (AEA) with spina bifida served in the Movin' On Up HCT program will be presented.

RESULTS

Through our clinical and research healthcare transition experience, insights pertaining to self-management will be presented.

CONCLUSION

The acquisition of self-management knowledge and skills is a complex process that extends far beyond learning the fundamental skills of daily condition management.