Adult Provider Perspectives on Transition and Transfer to Adult Care: A Multi-Specialty, Multi-Institutional Exploration

Young adults' perception of transition from paediatric to adult care

AIM

Medical advancements will lead to more children with long-term illnesses and/or disabilities undergoing the transition to adult care. Previous studies show that many young adults are unprepared for this transition, and might suffer from loss of follow-up. This study aimed to investigate the post-transfer experiences of the transition among young adults with long-term illnesses and/or disabilities.

METHODS

A qualitative descriptive design was used. Three semi-structured focus group interviews were conducted with 15 participants (18-25 years of age) recruited via patient organisations focusing on children and young adults with disabilities and/or long-term illnesses. The interviews were analysed with conventional content analysis.

RESULTS

One theme emerged: limbo, defined as an indefinite experience without knowing when or even if something would happen, or whether they would be overlooked. The theme rested on four categories: transition experiences, organisational aspects, influence on daily life, and self-management.

CONCLUSION

Areas for improvement were identified across the entire transition that is, in the preparation, transfer, and post-transfer stages. Our findings indicate a limited understanding among healthcare providers (HCPs) that the transition continues until the young adult has been fully integrated into adult care.

Incorporating the Six Core Elements of Health Care Transition in Type 1 Diabetes Care for Emerging Adults

A growing body of literature finds persistent problems in the provision of recommended health care transition services, as well as adverse outcomes associated with the lack of these services in emerging adults with type 1 diabetes. The Six Core Elements of Health Care Transition offers a structured approach to the phases of health care transition support for both pediatric and adult diabetes practices. This article reviews strategies to incorporate the Six Core Elements into ambulatory diabetes care to support successful health care transition for emerging adults with type 1 diabetes.

Features of Studies on Transition Interventions for Childhood Cancer Survivors: A Scoping Review

PURPOSE

in this scoping review, previously reported data were described and synthesized to document transition interventions in CCSs, and the features of intervention components of the current transition studies for CCSs were summarized.

METHODS

A literature search was conducted in PubMed, Web of Science, EMBASE, PsycINFO, CINAHL, Ovid, and the Cochrane Library following the PRISMA-ScR statement. All original studies (n = 9) investigating transition interventions in CCSs were included.

RESULTS

The current studies identified essential elements for transition programs, such as delivering knowledge, developing skills for coordination of care, and addressing psychosocial needs. However, the current transition interventions were generally in their infancy, and major deficits were found, including poorly reported intervention components and procedures, a limited number of relevant validated outcomes, and a failure to incorporate conceptual frameworks and international consensus statements.

CONCLUSIONS

This scoping review mapped current evidence of transition interventions for CCSs and highlighted the paucity of data in this area. More high-quality and well-reported randomized controlled trials are needed for the enrichment and standardization of future transition interventions.

Current approach to health care transition and integration into adult care for pediatric liver transplant recipients: A call for partnership

Despite the increased risk of non-adherence, allograft rejection, and mortality following transfer from pediatric to adult care in liver transplantation (LT), there is no standardized approach to health care transition (HCT). Two electronic national surveys were developed and distributed to members of the Society for Pediatric Liver Transplantation and all adult LT programs in the United States to examine current HCT practices. Responses were received from 40 pediatric and 79 adult centers. Pediatric centers were more likely to focus on HCT noting the presence of a transition/transfer policy (60.2% vs. 39.2%), transition clinic (51.6% vs. 16.5%), and the routine use of transition readiness assessment tools (54.8% vs. 10.2%). Perceived barriers to HCT were similar among pediatric and adult respondents and included patient willingness to transfer and participate in care, failure to show for appointments, and lack of sufficient time and staffing. These results highlight the need for an increased awareness of HCT at both pediatric and adult LT centers. The path to improvement requires a partnership between pediatric and adult providers. Recognizing the importance of a comprehensive HCT program initiated in pediatrics and continued throughout young adulthood with ongoing support by the adult team is essential.

The experiences of adolescent solid organ transplantation recipients, parents, and healthcare professionals in healthcare transition: A qualitative systematic review

PROBLEM

The transition from paediatric-centred to adult healthcare services in adolescent solid organ transplantation recipients is a period of increased risk and vulnerability, the issues related to healthcare transition have become key concerns to the healthcare community.

ELIGIBILITY CRITERIA

Qualitative studies of any design and qualitative components of mixed method studies that explored the experiences of healthcare transition among adolescent solid organ transplant recipients, parents, and healthcare professionals were included.

SAMPLE

Nine articles were finalised and included in the review.

METHODS

A systematic review of qualitative studies was conducted. Databases searched were Scopus, PsycINFO, EMBASE, Web of Science, PubMed, CINAHL and ProQuest Dissertations and Theses. Studies published between the inception of respective database and December 2022 inclusive were considered. A three-step inductive thematic synthesis method outlined by Thomas and Harden was used to form descriptive themes and the 10-item Joanna Briggs Institute Critical Appraisal Checklist was utilised to appraise the quality of included articles.

RESULTS

Two hundred and twenty studies were screened, and 9 studies published between 2013 and 2022 were included. Five analytical themes were generated: 'the struggle of being an adolescent with a transplant'; 'perceptions of transition'; 'the role of parents'; 'lack of transition readiness' and 'the need for better support'.

CONCLUSIONS

Adolescent solid organ transplant recipients, parents, and healthcare professionals faced multiple challenges in the healthcare transition.

IMPLICATIONS

Future interventions and health policies should provide targeted intervention strategies that address the barriers present in the healthcare transition to facilitate the optimization of the youth healthcare transition.

Adult and child and adolescent psychiatrists' experiences of transition in anorexia nervosa: a qualitative study

BACKGROUND

Young patients suffering from anorexia nervosa (AN) frequently need further treatment in Adult Mental Health Services (AMHS). The transition period from Child and Adolescent Mental Health Services (CAMHS) to AMHS is a critical time, with a high risk of disengagement from healthcare. We explored physicians' perspectives of the transition to triangulate the multiple perspectives of physicians, parents and those with a lived AN experience to more comprehensively characterize the challenges in this process of treatment transition.

METHODS

Using purposive sampling, we recruited 16 physicians confronted with transition in AN (adult psychiatrists, child and adolescent psychiatrists and pediatrician) and conducted semi-structured interviews, which were anonymized, transcribed, and analyzed following the reflexive thematic analysis framework.

RESULTS

Our analysis produced three main themes. First, a shared agreement on the transition's malfunction, where participants depicted transition as a dissatisfying, violent event. Second, the conception of AN as a disorder with specific needs, challenging the transition process especially regarding physicians' engagement. Finally, the ideal transition conceived as a serene experience of separation, with unanimous agreement on the necessity to start the transition depending on patients' needs rather than their age, in order to turn transitions into moments of care.

CONCLUSION

Our results are in line with other qualitative research studying transition in AN and in other chronic diseases, either focusing on the experience of healthcare workers, families, or patients. Our research shows transition in AN as an anxiety-inducing experience for physicians, patients and families alike. Moreover, we highlight a gap in the way physicians perceive and assist the patient's greater autonomy, depending on their specialty. Helping physicians to manage their patient's autonomy, which is a cornerstone of the transition readiness concept, could be a very efficient way to improve transitions in AN. Anorexia Nervosa (AN) is a severe disease, which most of the time starts during adolescence. Transition from Child and Adolescent Mental Health Services to Adult Mental Health Services is at risk of disengagement from healthcare. In order to better understand this process, we interviewed expert physicians about their experiences of transition in AN using a qualitative thematic analysis which highlighted three main themes. First, a shared agreement on the transition's malfunction. Second, the conception of AN as a disorder with specific needs challenging the transition process. Finally, the ideal transition conceived as a serene experience of separation, which needs to be started depending on patients' needs rather than their age. We also show differences in the way physicians perceive and assist the patient's greater autonomy acquired during the transition. Helping physicians to support their patients in acquiring autonomy, which is a cornerstone of the transition readiness concept, could be a very efficient way to improve transitions in AN.

The Transition to Adulthood for Youth Living with Rare Diseases

More children with rare diseases survive into adulthood. The transition period to adult healthcare presents many challenges for pediatric rare diseases. Few adolescents or their families receive any transitional support for the transition to adult healthcare or for their maturing psychosocial needs. Understanding the challenges in the transition process is critical to ensure that interventions designed to improve the transition are holistic and meet the needs of the youth and their families. Few transition programs are in place to meet the needs of those youth with rare diseases who cannot participate in medical decision making or who live independently because of severe disabilities and comorbidities. We searched the literature on preparation and outcomes for youth living with rare diseases in PubMed, CINAHL, and PsychInfo, excluding publications before 2010. The results revealed seven studies specific to rare diseases, special needs, or chronic conditions. Next, we discussed transition with experts in the field, GotTransition.org, and citation chaining, yielding a total of 14 sources. The barriers and challenges to transition were identified. Articles discussing solutions and interventions for transition in medically complex children were categorized care coordination or transition readiness. A large portion of children with rare disease are underserved and experience health disparities in transition.

Provider perspectives of barriers and facilitators to the transition from pediatric to adult care: a qualitative descriptive study using the COM-B model of behaviour

Objectives

Transition of care can be a complex process that involves multiple providers working together across the pediatric and adult health care system to support youth. The shift from a primarily family-centred approach to a patient-centred approach that emphasizes more personal responsibility for health care management can be challenging for youth, caregivers and providers to navigate. Despite the importance of transition, there is a lack of evidence about the best practices and types of interventions that support the transition of care process from the perspective of both pediatric and adult health care providers. An exploration of barriers and facilitators is a critical first step to identifying important behavioural determinants for designing and implementing evidence-based interventions. As such, the purpose of this study was to identify the barriers and facilitators to the transition of care from the perspective of pediatric and adult health care providers.

Methods

A qualitative descriptive design was used to conduct semi-structured interviews guided by the COM-B Model of Behaviour – a theoretical model that suggests that for any behaviour to occur there must be a change in one or more of the following domains: capability, opportunity and/or motivation. The study took place in the province of Nova Scotia, Canada and focused on three common conditions: Inflammatory Bowel Disease, Diabetes, and Juvenile Idiopathic Arthritis. Participants were recruited through stratified purposeful and convenience sampling and all interviews were conducted virtually on Zoom. Interviews were audio-recorded, transcribed verbatim and imported into NVivo Qualitative Data Software for analysis. Data were first analyzed using directed content analysis, guided by the COM-B model, then further examined using inductive thematic analysis to identify barriers and facilitators within the three domains.

Results

In total, 26 health care providers participated in this study (pediatric, n=13, adult n=13) including a mix of adult and pediatric physicians, nurses, and allied health care professionals. The participants identified primarily as female (n=19.73%) and had a range of years of experience (3–39, mean = 14.84). We identified a range of interconnected barriers and facilitators across each of the COM-B Model of Behaviour domains such as, degree of formalized training (capability), facilitation and coordination responsibilities (opportunity), collaboration across providers (opportunities), securing attachment to adult care system (motivation) and time (opportunity). Findings were categorized by three overarching themes: (1) Knowledge and Skills to Support Transition of Care; (2) Navigation Role for Youth and Caregivers; and (3) System Coordination.

Conclusions

By using the COM-B Model of Behaviour, we identified key barriers and facilitators that intersect to influence the transition of care process. These findings will be used to inform and adapt initiatives and interventions in Nova Scotia to improve the transition experience, as well as may be transferrable to other jurisdictions.

Improving the Transition of Adolescents from Disadvantaged Backgrounds from Pediatric to Adult Primary Care Providers

BACKGROUND

The lack of structured transition interventions for adolescents aging out of pediatric care is associated with poor health outcomes.

METHODS

We assessed the effectiveness of a transition protocol that aimed to improve the transfer of adolescents to adult primary care. Chart reviews were conducted on 21- and 22-year-old patients seen 18 months before and after protocol implementation. Completion of an adult medicine appointment scheduled within 6 months from the last pediatric visit was the primary outcome of interest.

FINDINGS

In pre-implementation period, 20.9% of patients versus 39.3% in post-implementation period were transferred. Transfer was higher in patients who had a dedicated transition visit, had a transition order placed, and were tracked during the transfer process.

DISCUSSION

A transition protocol can increase the number of adolescents who transfer to adult care. Once a patient is ready to transition, a dedicated transition visit is ideal; however, providers should incorporate transition care during any clinical encounter. While an electronic transition order can facilitate appointment scheduling, patient tracking and appointment reminders can help ensure appointment completion. In addition, all clinical staff should receive transition training and clinicians should be frequently reminded about the need to transition their patients. However, even with these efforts to support transition, the majority of patients did not do so, which indicates a continued need to develop and evaluate transition interventions.

PRACTICE IMPLICATIONS

Implementing a transition protocol in pediatric clinics can improve the transition of adolescents aging out of pediatric care and may diminish gaps in medical care that can be associated with poor health outcomes.