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Turchi RM, Kuo DZ, Rusher JW, Seltzer RR, Lehmann CU, Grout RW. Considerations for Alternative Decision-Making When Transitioning to Adulthood for Youth With Intellectual and Developmental Disabilities: Policy Statement. Pediatrics 2024; 153:e2024066841. [PMID: 38804066 DOI: 10.1542/peds.2024-066841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 05/29/2024] Open
Abstract
With advances in medical care, more youth with intellectual and/or developmental disabilities (IDD) are transitioning into adulthood. Patient- and family-centered, integrated care is warranted around this time of transition. Support teams (including the youth, caregivers, teachers, and pediatricians) should engage in transition planning, ideally starting between 12 and 14 years of age, to identify and develop resources to support the maturing youth's capacity for independent decision-making. Care teams should consider the varied levels of alternative decision-making support, which may include supported decision-making, medical proxy decision-making, power of attorney, and/or establishment of legal guardianship arrangements, to support the youth's health and well-being optimally. Ultimately, if independent decision-making is not appropriate, the goal for youth with IDD should be the least restrictive alternative, while preserving human rights and human dignity and promoting their autonomy. These considerations review alternative decision-making support, concepts, and legal requirements available for youth with IDD and their care teams. Pediatricians can support youth with IDD and their families in the transition process and decision-making autonomy by actively engaging the youth in care decisions, supporting needs for augmentative communication, fostering their expression of preferences and understanding of care decisions, and linking them to resources such as the medical-legal partnership model.
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Affiliation(s)
- Renee M Turchi
- Department of Pediatrics, Drexel University College of Medicine & St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Dennis Z Kuo
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - John W Rusher
- Department of Pediatrics, University of North Carolina School of Medicine in Chapel Hill, Chapel Hill, North Carolina
| | - Rebecca R Seltzer
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Randall W Grout
- Division of Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Regenstrief Institute, and Eskenazi Health, Indianapolis, Indiana
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Joseph PL, Gonçalves C, Applewhite J, Fleary SA. Examining provider anticipatory guidance for adolescents' preventive health: A latent class approach. J Pediatr Nurs 2024; 76:e117-e125. [PMID: 38429211 DOI: 10.1016/j.pedn.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Low rates of anticipatory guidance (AG) are reported across studies with adolescents, and little is known about how these conversations differ across early versus middle adolescence. This study explored adolescent-provider AG conversations for preventive health skills; the study objectives were to (1) identify patterns of provider-adolescent AG conversations across early and middle adolescence and (2) determine socio-demographic characteristics associated with these AG conversations. DESIGN AND METHOD Data from the 2019 National Survey of Children's Health were used to identify patterns of provider-adolescent AG conversations. The sample included 5500 early and 6730 middle adolescents (Mage = 14.67 years old, SD = 1.71, 51.7% boys, 79% White). Multiple group latent class analysis and multinomial regressions were estimated using four indicators of AG conversations (i.e., skills to manage health and healthcare, changes in healthcare that happen at 18, making positive choices about health, and receiving a medical history summary). RESULTS Three types of AG conversations were identified: high AG, low AG, and parent unaware. Among early and middle adolescents, adolescents that were older, girls, had private health insurance, and a personal provider were less likely to receive high AG compared to other types of AG. CONCLUSIONS Policies and strategies to engage adolescents in AG conversations during and outside of the medical appointment are needed. PRACTICE IMPLICATIONS Tools, such as brief screeners, can be used to ensure all adolescents are receiving high AG. School-based health centers, community centers and organizations, and telehealth appointments with medical professionals may be additional opportunities for adolescents to receive AG.
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Affiliation(s)
- Patrece L Joseph
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27599, USA.
| | | | - Janelle Applewhite
- Department of Educational Foundations and Exceptionalities, James Madison University, USA
| | - Sasha A Fleary
- Graduate School of Public Health and Health Policy, City University of New York, USA
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Tornivuori A, Kallio M, Culnane E, Pasanen M, Salanterä S, Sawyer S, Kosola S. Transition readiness and anxiety among adolescents with a chronic condition and their parents: A cross-sectional international study. J Adv Nurs 2024; 80:756-764. [PMID: 37691321 DOI: 10.1111/jan.15860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 08/14/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
AIMS To evaluate associations of age, transition readiness and anxiety in adolescents with chronic conditions and to compare perceptions of adolescents and their parents regarding health self-management and transition readiness. DESIGN Cross-sectional international study, reported following STROBE guidelines. METHODS Adolescents and young adults (N = 512, mean age 17.7) with a chronic medical condition and their parents (N = 322) from Finland and Australia. Data were collected through surveys (between September 2017 and December 2020). Adolescents reported the duration of their condition. Age at survey was defined by the response date of the questionnaires. Validated questionnaires were used to measure transition readiness (Am I ON TRAC? for Adult Care) and anxiety related to transition of care (State-Trait Anxiety Inventory short form). Perceptions of health self-management and transition readiness were compared in adolescent/parent dyads. Associations were explored using Spearman's correlation. RESULTS Duration of condition and age at survey correlated weakly with transition readiness knowledge and behaviour. Higher transition readiness knowledge scores correlated with higher behaviour scores. Higher transition readiness behaviour scores were associated with lower levels of anxiety. Adolescents were less anxious than their parents and adolescents and parents mostly agreed about health self-management and transition readiness. CONCLUSION Transition readiness should be determined by an assessment of knowledge, self-management and psychosocial skills instead of age alone. Further research should address how well transition readiness predicts positive health outcomes after the transfer of care. IMPLICATIONS FOR PATIENT CARE Transition readiness and self-management skills should be formally assessed because positive feedback may decrease the anxiety of both adolescents and their parents regarding the transfer of care. REPORTING METHOD We have adhered to the STROBE statement, using STROBE checklist for cross-sectional studies. PATIENT OR PUBLIC INVOLVEMENT STATEMENT No patient or public involvement. TRIAL AND PROTOCOL REGISTRATION ClinicalTrials.org NCT04631965.
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Affiliation(s)
- Anna Tornivuori
- Nursing Science, University of Turku, Turku, Finland
- Nursing Research Center NRC, Helsinki University Hospital, Helsinki, Finland
- Pediatric Research Center, New Children's Hospital, Helsinki, Finland
| | - Mira Kallio
- Pediatric Research Center, New Children's Hospital, Helsinki, Finland
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Evelyn Culnane
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Miko Pasanen
- Nursing Science, University of Turku, Turku, Finland
| | - Sanna Salanterä
- Nursing Science, University of Turku, Turku, Finland
- Turku University Hospital, Turku, Finland
| | - Susan Sawyer
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Adolescent Medicine, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Silja Kosola
- Pediatric Research Center, New Children's Hospital, Helsinki, Finland
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Leake E, Koopmans E, Sanders C. Primary Care Providers Involvement in Caring for Young Adults with Complex Chronic Conditions Exiting Pediatric Care: An Integrative Literature Review. Compr Child Adolesc Nurs 2023; 46:201-222. [PMID: 32191128 DOI: 10.1080/24694193.2020.1733707] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
The transition to adulthood is a critical time for everyone to build independence, experience new things, and become self-sufficient. With medical advances, individuals with complex chronic conditions are surviving into adulthood. As such they withstand additional challenges during this stage of their life including; facing a discontinuity of care, loss of prior health-care networks and champions, and a shift toward increased responsibility and self-management of their conditions. Often this shift results in the need for primary care providers to act as care managers, coordinating care and supporting the young adult as they navigate adulthood. In exploring the role of primary care providers with this population we reviewed the literature to identify what strategies primary care providers can use to enhance the transition process for young adults ages 15 to 25 years with complex chronic conditions exiting pediatric services. An integrative literature review approach was used to systematically search the contemporary literature. Applying inclusion criteria and quality assessment of relevant research and gray literature we identified 12 studies that warranted detailed review and analysis. Analysis of the studies highlighted four key themes: relationships, fear and anxiety, preparedness, and communication and collaboration. It was evident that health-care transition for young adults with complex chronic conditions was complicated by their psychosocial development and extensive health and service needs. Health-care transition is a team effort influenced by local contexts, resources, and relational practices. Both groups of primary care providers and young adults must be prepared prior to transition if they are to become immersed and engaged in this work. The population of young adults with complex chronic conditions exiting pediatric care will continue to grow as access to care delivery and medical technology continue to expand. While health-care transition for this population is complicated by extensive needs and psychosocial development, primary care providers can act as key supports in employing strategies to enhance the transition process for these young adults.
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Affiliation(s)
- Emily Leake
- Urban Native Youth Association, Vancouver, British Columbia, Canada
| | - Erica Koopmans
- Health Research Institute, University of Northern British Columbia, Prince George, British Columbia, Canada
- School of Nursing, University of Northern British Columbia, Prince George, British Columbia, Canada
| | - Caroline Sanders
- School of Nursing, University of Northern British Columbia, Prince George, British Columbia, Canada
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Traino KA, Fisher RS, Basile NL, Edwards CS, Bakula DM, Chaney JM, Mullins LL. Transition readiness and quality of life in emerging adult college students. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2023; 71:1167-1174. [PMID: 34242532 DOI: 10.1080/07448481.2021.1923507] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/23/2021] [Accepted: 04/25/2021] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To examine the relative contribution of transition readiness (i.e., healthcare self-management) to health-related quality of life (HRQoL) among emerging adult (EA) college students without a chronic medical condition (CMC).Participants: College students (n = 2372; Mage = 19.32, SD = 1.26) from a Midwestern university.Methods: Participants completed online measures of demographics, HRQoL, and transition readiness.Results: Hierarchical regression analyses found transition readiness accounted an additional 3-4% of the variability in mental and physical HRQoL (p < .001), beyond demographic factors. 11.3% of EAs reported overall mastery of transition readiness, with navigating health insurance being the weakest area.Conclusions: Findings support the consensus that transition readiness is relevant to HRQoL for all EAs, including those without a CMC. EAs without a CMC demonstrate relatively weak transition readiness skills. Primary and university-based healthcare might consider programs supporting transition readiness and HRQoL among underresourced EAs.
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Affiliation(s)
- Katherine A Traino
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Rachel S Fisher
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Nathan L Basile
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Clayton S Edwards
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Dana M Bakula
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - John M Chaney
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Larry L Mullins
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
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Radtke HB, Berger A, Skelton T, Goetsch Weisman A. Neurofibromatosis Type 1 (NF1): Addressing the Transition from Pediatric to Adult Care. Pediatric Health Med Ther 2023; 14:19-32. [PMID: 36798587 PMCID: PMC9925753 DOI: 10.2147/phmt.s362679] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
Health care transition, or HCT, is the process of adolescents and young adults moving from a child/family-centered model of health care to an adult/patient-centered model of health care. Healthcare providers have an essential role in this process which can be especially challenging for individuals with medical or special healthcare needs. Neurofibromatosis type 1 (NF1) is a complex multisystem disorder requiring lifelong medical surveillance, education, and psychosocial support. This review highlights the transition needs of NF1 patients and provides resources for both clinicians and families to facilitate HCT in this population. The authors propose a framework for the development of an effective NF1 transition program by using the Six Core Elements model of the Got Transition program, reviewing existing literature, and incorporating author experiences in the care and transition of NF1 patients.
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Affiliation(s)
- Heather B Radtke
- Medical College of Wisconsin, Milwaukee, WI, USA,Children’s Tumor Foundation, New York, NY, USA,Correspondence: Heather B Radtke, Email
| | - Angela Berger
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Tammi Skelton
- UAB Heersink School of Medicine, Birmingham, AL, USA
| | - Allison Goetsch Weisman
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA,Northwestern University, Chicago, IL, USA
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Quintero J, Rodríguez-Quiroga A, Álvarez-Mon MÁ, Mora F, Rostain AL. Addressing the Treatment and Service Needs of Young Adults with Attention Deficit Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am 2022; 31:531-551. [PMID: 35697400 DOI: 10.1016/j.chc.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The transition from adolescence to adulthood is a complex period in which multiple changes take place (education, work, independent living, and social relations). This stage is especially difficult for adolescents suffering from attention deficit hyperactivity disorder (ADHD), who have to move on from child and adolescent mental health services to adult mental health services. This review analyzes developmental and environmental risk and protective factors as well as critical variables such as executive functioning and self-monitoring that influence the course of ADHD in transitional age youth and guide the priorities for an optimal transition of care. The influence of the COVID-19 pandemic is also discussed. We reflect on the unmet needs for an optimal transition of care and propose practice and policy recommendations to achieve this goal.
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Affiliation(s)
- Javier Quintero
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Legal Medicine & Psychiatry, Complutense University, Spain.
| | - Alberto Rodríguez-Quiroga
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Legal Medicine & Psychiatry, Complutense University, Spain
| | - Miguel Ángel Álvarez-Mon
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcala, 28801 Alcala de Henares, Spain; Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Fernando Mora
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Legal Medicine & Psychiatry, Complutense University, Spain
| | - Anthony L Rostain
- Department of Psychiatry, Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ 08103, USA
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Lestishock L, Nova S, Disabato J. Improving Adolescent and Young Adult Engagement in the Process of Transitioning to Adult Care. J Adolesc Health 2021; 69:424-431. [PMID: 33762131 DOI: 10.1016/j.jadohealth.2021.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/14/2020] [Accepted: 01/23/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Health care transition (HCT) is the complex process of changing from pediatric to adult-centered care. Comprehensive HCT processes have been associated with improved outcomes in all elements of the Triple Aim. Nationally accepted best practices emphasize Six Core Elements of HCT, including the use of transition readiness assessment tools completed during clinic visits. Specifically, Got Transition's tools include two 0-10 point self-report scales on the validated domains of importance of changing to an adult provider and managing their healthcare, and confidence in their ability to transition. The aim of this quality improvement project (QIP) was to improve the engagement of adolescents and young adults (AYAs), aged 14-20, in the process of transitioning from pediatric to adult care. The sub-aim focused specifically on parent/caregiver engagement in transition, using the same scales in a tool for parents/caregivers. An urban federally qualified health center initiated this QIP. METHODS This QIP utilized the Institute for Healthcare Improvement Model for Improvement and plan-do-study-act cycles. RESULTS Eighty-five AYAs and 40 parents/caregivers completed readiness assessments twice. Scores improved overall, reaching statistical significance with a small change in AYA mean scores for importance (.94) and confidence (.75). Provision of a transition policy and completion of readiness assessments by AYAs and parents/caregivers met the 70% goal. Patient portal enrollments increased from 4.2% to 12.5%, although did not meet the 30% goal. CONCLUSIONS Engagement of AYAs and parents/caregivers was improved as a result of this QIP. Successful routine implementation of transition process measures demonstrated improved clinic-wide communication.
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Affiliation(s)
- Lisa Lestishock
- Ravenswood Family Health Center, East Palo Alto, California; Division of Adolescent Medicine, Stanford Children's Health, Menlo Park, California.
| | - Sandra Nova
- Ravenswood Family Health Center, East Palo Alto, California
| | - Jennifer Disabato
- College of Nursing & School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Rea KE, Cushman GK, Quast LF, Stolz MG, Mee LL, George RP, Blount RL. Specific healthcare responsibilities and perceived transition readiness among adolescent solid organ transplant recipients: Adolescent and caregiver perspectives. PATIENT EDUCATION AND COUNSELING 2021; 104:2089-2097. [PMID: 33549384 DOI: 10.1016/j.pec.2021.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/28/2020] [Accepted: 01/22/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Adolescents and young adults (AYAs) with solid organ transplants must attain responsibility for healthcare tasks during transition to adult healthcare. However, healthcare systems often initiate transfer based on age and not independence in care. This study examines specific responsibilities distinguishing AYA organ transplant recipients reporting readiness to transfer. METHODS 65 AYAs (ages 12-21) with heart, kidney, or liver transplants and 63 caregivers completed questionnaires assessing AYA's transition readiness, healthcare responsibility, and executive functioning. Categorizations included mostly/completely ready versus not at all/somewhat ready to transition; responsibility was compared between groups. RESULTS 42% of AYAs and 24% of caregivers reported AYAs as mostly/completely ready to transition. AYAs mostly/completely ready reported similar routine healthcare responsibility (e.g., medication taking, appointment attendance), but greater managerial healthcare responsibility (e.g., knowing insurance details, appointment scheduling), compared to AYAs not at all/somewhat ready to transition. CONCLUSIONS All AYAs should be competent in routine healthcare skills foundational for positive health outcomes. However, the managerial tasks distinguish AYAs perceived as ready to transfer to adult healthcare. PRACTICE IMPLICATIONS Emphasis on developing responsibility for managerial tasks is warranted. The Hierarchy of Healthcare Transition Readiness Skills is a framework by which AYA responsibility can be gradually increased in preparation for transfer.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology University of Georgia, Athens, USA.
| | | | - Lauren F Quast
- Department of Psychology University of Georgia, Athens, USA
| | | | - Laura L Mee
- Emory/Children's Pediatric Institute, Atlanta, USA
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Collette P, Klein LC, Körner LM, Ernst G, Brengmann S, Schäuble J, Habbig S, Weber LT. The individualized, accompanied transition program “TraiN” for adolescent kidney patients – a local initiative. JOURNAL OF TRANSITION MEDICINE 2021. [DOI: 10.1515/jtm-2021-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Since the transition from pediatric and adolescent to adult care often proceeds unaccompanied and unplanned, young patients with chronic kidney disease may experience health risks and non-adherence after the transfer. The psychosocial team at the Department of Pediatric Nephrology at the University Hospital of Cologne has therefore developed its local transition program “TraiN” for patients with chronic kidney disease aged 13 years and older. It combines structure and flexibility through predefined content modules that can be individually adapted to the patients, offering continuity and sustainability through a transition contact person. In addition, the family members are offered regular psychological consultations. The timing of the transfer is chosen individually depending on the level of psychosocial and medical transition readiness. The aim of “TraiN” is to strengthen the patients’ transition competence and the responsibility for their disease management and to provide them and their families the best possible support during the transition in order to prevent possible health risks. In the near future, a scientific evaluation will be conducted aiming to determine whether “TraiN” can support young people in their independence and self-reliant disease management.
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Affiliation(s)
- Paula Collette
- Nephrology, Children’s and Adolescent’s Hospital , Faculty of Medicine and University Hospital of Cologne, University of Cologne , Cologne , Germany
| | - Luisa C. Klein
- Nephrology, Children’s and Adolescent’s Hospital , Faculty of Medicine and University Hospital of Cologne, University of Cologne , Cologne , Germany
| | - Lisa M. Körner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology , University Children’s Hospital, Medical Faculty, Heinrich-Heine-University , Düsseldorf , Germany
| | - Gundula Ernst
- Department of Medical Psychology , Hannover Medical School , Hannover , Germany
| | - Sandra Brengmann
- Nephrology, Children’s and Adolescent’s Hospital , Faculty of Medicine and University Hospital of Cologne, University of Cologne , Cologne , Germany
| | - Julian Schäuble
- Nephrology, Children’s and Adolescent’s Hospital , Faculty of Medicine and University Hospital of Cologne, University of Cologne , Cologne , Germany
| | - Sandra Habbig
- Nephrology, Children’s and Adolescent’s Hospital , Faculty of Medicine and University Hospital of Cologne, University of Cologne , Cologne , Germany
| | - Lutz T. Weber
- Nephrology, Children’s and Adolescent’s Hospital , Faculty of Medicine and University Hospital of Cologne, University of Cologne , Cologne , Germany
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Andreoli A, Klingbeil C. Implementing Pediatric Transition Education Initiative During Inpatient Admissions in the Epilepsy Monitoring Unit. J Pediatr Nurs 2021; 57:50-55. [PMID: 33242830 DOI: 10.1016/j.pedn.2020.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Ashley Andreoli
- Medical College of Wisconsin, Children's Wisconsin, WI, United States of America.
| | - Carol Klingbeil
- University of Wisconsin Milwaukee, WI, United States of America.
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Abstract
Without a structure to address healthcare transition, adolescents and young adults with neurological disorders are likely to have disruptions in their care that result in a higher need for emergency care and hospitalization. There are numerous obstacles to implementing the existing transition guidelines: adequate numbers of skilled and willing adult providers, patient and family anxiety about transfer, changes in health insurance, inadequate reimbursement, and inefficient communication systems to pave the path for a smooth transition. The aim of this article is to provide practical information about developing a transition program, as well as a potential clinical model for transitioning care.
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Affiliation(s)
- Mary L Zupanc
- Department of Neurology and Pediatrics, Pediatric Comprehensive Epilepsy Program, University of California-Irvine, Children's Hospital of Orange County, Orange, CA..
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13
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Nurre ER, Smith AW, Rodriguez MG, Modi AC. Patient, Caregiver, and Provider Perceptions of Transition Readiness and Therapeutic Alliance during Transition from Pediatric to Adult Care in Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1716914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractTransition from pediatric to adult health care is a time of high risk for adolescents and young adults (AYAs) with epilepsy. Our aims are to examine patient, caregiver, and provider perceptions of transition readiness and the influence of patient-provider alliance in the context of transition readiness. Our cross-sectional study included 82 AYAs with epilepsy prior to transition. Patients, caregivers, and providers completed questionnaires (e.g., transition readiness and working alliance). Statistical analyses included independent samples and paired t-tests. Participants were 17.3 ± 2.8 years on average, 54% were females, 84% were White (non-Hispanic), and 38% had generalized epilepsy. Caregivers reported significantly higher transition readiness than their AYAs (t (72) = −10.6, p < 0.001). AYAs and providers reported similar alliance scores. Providers who felt patients were ready to transition had higher patient-reported transition readiness and provider-reported alliance scores. These data suggest that patients and providers are well aligned in the transition process, and providers appropriately perceive key areas necessary for transition. Caregivers and patients had discrepant perceptions of transition readiness, highlighting the importance of assessing both unique transition perspectives. Dedicated transition programs are likely to be beneficial in improving transition readiness and increase alignment across patients, caregivers, and providers.
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Affiliation(s)
- Emily R. Nurre
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Aimee W. Smith
- Department of Psychology, East Carolina University, Greenville, North Carolina, United States
| | - Marie G. Rodriguez
- Department of Psychology, East Carolina University, Greenville, North Carolina, United States
| | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
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Twanow JDE, Maturu S, Khandker N. Pediatric to Adult Epilepsy Transition in Ambulatory Care: Benefits of a Multidisciplinary Epilepsy Transition Clinic. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1716827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractChildren with epilepsy comprise 3.2% of the estimated 500,000 youth with special medical needs who move from the pediatric to adult care model annually. These 16,000 children who require transfer each year represent a challenging subset of 470,000 youth living with epilepsy in the United States. Transition and transfer of care are complex and require gradual processes. This period for youth with epilepsy is often associated with inadequate follow-up and increased risk of nonadherence. Furthermore, youth and adults with epilepsy are known to have suboptimal social and emotional outcomes compared with peers, with high rates of under education, underemployment, poverty, and struggles with mental health. The goal of improving social determinants and continuity of care prompted the development of formal epilepsy transition clinics. Multiple clinic models exist, sharing the overarching goal of supporting youth while building self-management skills, tailored to age and developmental level. Early evidence shows that transition discussion leads to statistically significant increases in transfer readiness and self-efficacy in young adults with epilepsy. Our center boasts a 100% attendance rate at our transition and transfer clinic and 78% compliance with follow-up, further demonstrating that patients and families value quality transition programming.
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Affiliation(s)
- Jaime-Dawn E. Twanow
- Division of Neurology, Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University, Columbus, Ohio, United States
| | - Sarita Maturu
- Division of Epilepsy, Department of Neurology, Nationwide Children’s Hospital, Ohio State University, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Nabil Khandker
- Division of Epilepsy, Department of Neurology, Nationwide Children’s Hospital, Ohio State University, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
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Kaehne A, Kiernan J, Ridley J. Systematic review of study designs and methods in health transition research for young people with intellectual disabilities. Heliyon 2019; 5:e02750. [PMID: 31768431 PMCID: PMC6872843 DOI: 10.1016/j.heliyon.2019.e02750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/10/2019] [Accepted: 10/25/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Transition for young people with intellectual disabilities from paediatric or adolescent services into adult health care services remains a difficult process for all stakeholders. The study assessed the type of interventions, the methodological approaches, study designs and location of existing published evidence in health care transitions. METHODS A systematic review utilising the PRISMA protocol with an amended quality appraisal tool to explore the nature of published evidence on health care transitions for young people. RESULTS Findings demonstrate that health transition research for this population lacks a robust evidence base and researchers favour exploratory studies investigating the experiential dimension of transition. The lack of involvement of young people in the studies indicates a problematic absence of genuinely participatory research. CONCLUSION The study is the first systematic review of empirical studies in health transition of young people with intellectual disabilities exploring the nature of existing evidence. The results will support setting priorities for future research.
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Affiliation(s)
- Axel Kaehne
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Joann Kiernan
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - James Ridley
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
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Price A, Janssens A, Woodley AL, Allwood M, Ford T. Review: Experiences of healthcare transitions for young people with attention deficit hyperactivity disorder: a systematic review of qualitative research. Child Adolesc Ment Health 2019; 24:113-122. [PMID: 32677182 DOI: 10.1111/camh.12297] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by hyperactivity, inattention and impulsivity. Up to two thirds of young people with ADHD may experience symptoms into adulthood, yet the limited literature available suggests that many young people with ongoing needs do not transfer from child to adult healthcare services. Although worldwide and NICE guidelines recognise the importance of supported transition, evidence suggests for ADHD that this is poorly managed and variable. Little is known about how transition is experienced by those involved. We aimed to synthesise existing peer-reviewed literature to understand views and experiences of young people, carers and clinicians on transitioning between child and adult ADHD services. METHOD Five databases were searched and all articles published between 2000 and up until January 2017 considered. Four key search areas were targeted; ADHD, Transition, Age and Qualitative Research. Quality appraisal was conducted using Wallace criteria. Findings from included studies were synthesised using thematic analysis. RESULTS Eight papers, six from the UK and one each from Hong Kong and Italy, were included. Emerging themes centred on difficulties transitioning; hurdles that had to be negotiated, limitations of adult mental health services, inadequate care and the impact of transition difficulties. CONCLUSIONS Healthcare transition for this group is difficult in the United Kingdom because of multiple challenges in service provision. In addition to recommendations in NICE guidelines, respondents identified a need for better provision of information to young people about adult services and what to expect, greater flexibility around age boundaries and the value of support from specialist adult ADHD services. More research is needed into ADHD healthcare transition experiences, especially in countries outside the United Kingdom, including accounts from carers and clinicians.
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Affiliation(s)
- Anna Price
- University of Exeter Medical School, Exeter, UK
| | | | | | | | - Tamsin Ford
- University of Exeter Medical School, Exeter, UK
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17
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White PH, Cooley WC, Boudreau ADA, Cyr M, Davis BE, Dreyfus DE, Forlenza E, Friedland A, Greenlee C, Mann M, McManus M, Meleis AI, Pickler L. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics 2018; 142:peds.2018-2587. [PMID: 30348754 DOI: 10.1542/peds.2018-2587] [Citation(s) in RCA: 424] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Patience H. White
- Got Transition/The National Alliance to Advance Adolescent Health and Department of Medicine and Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and
| | - W. Carl Cooley
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Freeman M, Stewart D, Cunningham CE, Gorter JW. Information needs of young people with cerebral palsy and their families during the transition to adulthood: a scoping review. JOURNAL OF TRANSITION MEDICINE 2018. [DOI: 10.1515/jtm-2018-0003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractThe transition to adulthood is a developmental phase which occurs as young people move from adolescence into adulthood. Young people with disabilities, including cerebral palsy (CP), and their families have reported challenges during the transition to adulthood because they are required to move to adult supports and services, which are often fragmented and bring about new questions and expectations to find necessary supports. Young people and their parents have been found to lack information about where to find services in adulthood, how to access the services and what to ask during the transitional process. The aim of this scoping review was to explore the information needs of young people with CP and their families during the transition to adulthood. The goal is to map the current published evidence within the transition to adulthood literature base to explore what is known about information needs during the transition to adulthood of young people with CP and their parents. This review seeks to synthesize what is known about information content, timing, methods of provision and delivery. Databases searched were OVID Medline, CINAL, ERIC, EMBASE, PsycINFO, Web of Science, Social Science Abstracts and Sociological Abstracts. Initially 675 articles were retrieved. Four hundred and forty-two articles were selected for title review. Two hundred and five articles remained for abstract review. Seventeen articles were included for full-text review. Eleven articles were included in this review. Data were organized into five themes: (1) identified information needs during the transition to adulthood (content), (2) identified recommended providers of information during the transition to adulthood (who), (3) identified delivery methods of information during the transition to adulthood (how), (4) identified timing of information delivery of information during the transition to adulthood (when) and (5) location of information provided during the transition to adulthood (where). This review found that young people with CP, their families and adult providers all possess information needs during the transition to adulthood. Young people with CP and their families seek information about what adult services will look like and how to access supports. Adult providers require information about CP. Youth with CP prefer individualized information be delivered to them when needed rather than presented in group sessions or via paper handout. Other recommendations included the development of parent support networks to assist parents in the transition to adulthood. The opportunity to learn from real-life experiences was also viewed as an important source of information as well as method to provide information.
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Affiliation(s)
- Matthew Freeman
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
| | - Debra Stewart
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
| | - Charles E. Cunningham
- Faculty of Health Sciences, Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jan Willem Gorter
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Johnson EL, Frias JP, Trujillo JM. Anticipatory guidance in type 2 diabetes to improve disease management; next steps after basal insulin. Postgrad Med 2018; 130:365-374. [PMID: 29569978 DOI: 10.1080/00325481.2018.1452515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The alarming rise in the number of people living with type 2 diabetes (T2D) presents primary care physicians with increasing challenges associated with long-term chronic disease care. Studies have shown that the majority of patients are not achieving or maintaining glycemic goals, putting them at risk of a wide range of diabetes-related complications. Disease- and self-management programs have been shown to help patients improve their glycemic control, and are likely to be of particular benefit for patients with diabetes dealing with these issues. Anticipatory guidance is an individualized, proactive approach to patient education and counseling by a health-care professional to support patients in better coping with problems before they arise. It has been shown to improve disease outcomes in a variety of chronic conditions, including diabetes. While important at all stages, anticipatory guidance may be of particular importance during changes in treatment regimens, and especially during transition to, and escalation of, insulin-based regimens. The aim of this article is to provide advice to physicians on anticipatory guidance for basal-insulin dosing, focusing on appropriate basal-insulin-dose increase and prevention of potentially deleterious basal-insulin doses, so called overbasalization. It also provides an overview of new treatment options for patients with T2D who are not well controlled on basal-insulin therapy, fixed-ratio combinations of basal insulin and glucagon-like peptide-1 receptor agonists, and advice on the type of anticipatory guidance needed to ensure safe and appropriate switching to these therapies.
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Affiliation(s)
- Eric L Johnson
- a Department of Family and Community Medicine , University of North Dakota , Grand Forks , ND , USA
| | - Juan P Frias
- b National Research Institute , Los Angeles , CA , USA
| | - Jennifer M Trujillo
- c Skaggs School of Pharmacy and Pharmaceutical Sciences , University of Colorado , Aurora , CO , USA
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21
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Downing KF, Oster ME, Farr SL. Preparing adolescents with heart problems for transition to adult care, 2009-2010 National Survey of Children with Special Health Care Needs. CONGENIT HEART DIS 2017; 12:497-506. [PMID: 28523852 DOI: 10.1111/chd.12476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/06/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE A substantial percentage of children with congenital heart disease (CHD) fail to transfer to adult care, resulting in increased risk of morbidity and mortality. Transition planning discussions with a provider may increase rates of transfer, yet little is known about frequency and content of these discussions. We assessed prevalence and predictors of transition-related discussions between providers and parents of children with special healthcare needs (CSHCN) and heart problems, including CHD. DESIGN Using parent-reported data on 12- to 17-year-olds from the 2009-2010 National Survey of CSHCN, we calculated adjusted prevalence ratios (aPR) for associations between demographic factors and provider discussions on shift to adult care, future insurance, and adult healthcare needs, weighted to generate population-based estimates. RESULTS Of the 5.3% of adolescents with heart problems in our sample (n = 724), 52.8% were female, 65.3% white, 62.2% privately insured, and 37.1% had medical homes. Less than 50% had parents who discussed with providers their child's future health insurance (26.4%), shift to adult care (22.9%), and adult healthcare needs (49.0%). Transition planning did not differ between children with and without heart problems (aPR range: 1.0-1.1). Among parents of CSHCN with heart problems who did not have discussions, up to 66% desired one. Compared to 1-/13-year-olds, a larger percentage of 16-/17-year-olds had parents who discussed their shift to adult care (aPR 2.1, 95% confidence interval (CI) [1.1, 3.9]), and future insurance (aPR 1.8, 95% CI [1.1, 2.9]). Having a medical home was associated with discussing adult healthcare needs (aPR 1.5, 95% CI [1.2, 1.8]) and future insurance (aPR 1.8, 95% CI [1.3, 2.6]). CONCLUSIONS Nationally, less than half of adolescents with heart problems had parents who discussed their child's transition with providers, which could be contributing to the large percentage of CHD patients who do not successfully transfer to adult care.
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Affiliation(s)
- Karrie F Downing
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Matthew E Oster
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.,Children's Healthcare of Atlanta, Sibley Heart Center, Atlanta, Georgia
| | - Sherry L Farr
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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22
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Nakhla M, Bell LE, Wafa S, Dasgupta K. Improving the transition from pediatric to adult diabetes care: the pediatric care provider's perspective in Quebec, Canada. BMJ Open Diabetes Res Care 2017; 5:e000390. [PMID: 28761657 PMCID: PMC5530239 DOI: 10.1136/bmjdrc-2017-000390] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/12/2017] [Accepted: 05/16/2017] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES The transition from pediatric to adult care is a high-risk period for the emerging adult with diabetes. We aimed to determine adequacy of pediatric transition care structures and explore the pediatric diabetes care provider's perceptions of transition care. RESEARCH DESIGN AND METHODS In-depth interviews with pediatric diabetes care providers from 12 diabetes centers in Quebec were conducted. We queried alignment with Got Transition's six core elements of healthcare transition, experiences, and barriers to transition care. Interview transcripts were reviewed for themes. RESULTS Three centers (25%) reported having any elements of formal and structured transition care preparation and planning. When referrals were within center (n=8), pediatric providers perceived that transition was smoother; information sharing relied heavily on verbal communication rather than documented medical summaries. Barriers included lack of adult providers, less flexibility in adult care scheduling, patient struggles with multiple new adult responsibilities, and insufficient understanding by adult providers of these challenges. There was a perception that the quality of pediatric care was better than adult care. Moving out of the pediatric care geographical region appeared to increase risk for poor follow-up. Patient satisfaction and regular follow-up in adult care were thought to be good measures of transition success. Programs that included overlap between pediatric and adult care were perceived as ideal. CONCLUSIONS Important gaps in transition care practices persist. Efforts should focus on improving education in transition practices for pediatric care providers and establishing formal transition policies and structures at the institutional level.
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Affiliation(s)
- Meranda Nakhla
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Lorraine E Bell
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Sarah Wafa
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Kaberi Dasgupta
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
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