Helping Health Services to Meet the Needs of Young People with Chronic Conditions: Towards a Developmental Model for Transition

Ready to leave? - Adolescents' and parents' perceptions of transition from paediatric to adult rheumatology care

BACKGROUND

In Sweden, approximately 2000 children live with Juvenile Idiopathic Arthritis (JIA). About half of them continue to have an active disease and need to transfer to adult rheumatology care. This study aimed to investigate Swedish adolescents' and parents´ perceptions of readiness for transition from pediatric to adult rheumatology care.

METHODS

The study was a cross-sectional quantitative study. Patients at the pediatric rheumatology clinic at a university hospital in Sweden and members of The Swedish National Organization for Young Rheumatics aged 14-18 and their parents were invited to participate in the study. Data was collected with the Readiness for Transition Questionnaire (RTQ) focusing on adolescents' transition readiness, adolescents' healthcare behaviors and responsibility, and parental involvement. Data were analyzed with descriptive statistics. Comparative analyses were made using non-parametric tests with significance levels of 0.05 as well as factor analyses and logistic regression.

RESULTS

There were 106 adolescents (85 girls, 20 boys) and 96 parents answering the RTQ. The analysis revealed that many adolescents and parents experienced that the adolescents were ill-prepared to take over responsibility for several healthcare behaviors, such as booking specialty care appointments, calling to renew prescriptions and communicating with medical staff on phone and to transfer to adult care. Parents and adolescents alike stated that it was especially difficult for the adolescents to take responsibility for healthcare behaviors meaning that the adolescents had to have direct interaction with the healthcare professionals (HCPs) at the paediatric rheumatology clinic, for example to renew prescriptions. It was evident that the adolescents who perceived they were ready to take responsibility for the aspects related to direct interaction with HCPs were more overall ready to be transferred to adult care.

CONCLUSION

Adolescents need more support to feel prepared to transfer to adult care. With the results from this study, we can develop, customize, and optimize transitional care programs in Sweden for adolescents.

Parental Involvement in the Transition from Paediatric to Adult Care for Youth with Chronic Illness: A Scoping Review of the North American Literature

With medical advancements and improvements in medical technology, an increasing number of children with chronic conditions survive into adulthood. There is accordant growing interest toward supporting adolescents throughout the transition from paediatric to adult care. However, there is currently a paucity of research focusing on the role that these patients' parents should play during and after the transition to adult care and if maintained parental involvement is beneficial during this transition within a North American context. Accordingly, this scoping review utilized Arksey and O'Malley's five-step framework to consider parental roles during chronically ill children's transition to adult care. APA PsycInfo, CINAHL, EMBASE, MEDLINE, ProQuest, and Scopus were searched alongside advanced Google searches. Thematic content analysis was conducted on 30 articles meeting the following inclusion criteria: (1) published in English between 2010 and 2022, (2) conducted in Canada or the United States, (3) considered adolescents with chronic conditions transitioning to adult care, (4) family being noted in the title or abstract, and (5) patient populations of study not being defined by delays in cognitive development, nor mental illness. Three themes emerged from the literature: the impacts of maintaining parental involvement during transition to adult care for patients, parents experiencing feeling loss of stability and support surrounding the transition of their child's care, and significant nonmedical life events occurring for youths at the time of transition of care. Parents assuming supportive roles which change alongside their maturing child's needs were reported as being beneficial to young peoples' transition processes, while parents who hover over or micromanage their children during this time were found to hinder successful transitions. Ultimately, the majority of reviewed articles emphasized maintained parental involvement as having a net positive impact on adolescents' transitions to adult care. As such, practice and policies should be structured to engage parents throughout the transition process to best support their chronically ill children during this time of change.

Youth Work in the Hospital Setting: A Narrative Review of the Literature

This paper presents a narrative literature review on the evidence relating to the youth worker role with young people in the hospital setting, within which the research gaps and inconsistencies within the body of knowledge available are highlighted. Medline, CINAHL, PsycINFO, AMED and British Nursing Index databases were searched and screened for papers which involved the youth worker role with young people in a hospital setting. Data relating to the youth workers who worked with young people in the hospital setting were extracted by two independent reviewers. A total of 11 papers were identified dating from 1971 to 2018, from a range of countries. In order to present the available body of knowledge, this narrative synthesis of the literature is presented under three headings: descriptive work, service evaluation and empirical research. The findings suggest that the youth worker role in the hospital setting has a positive impact upon the lives of young people and this was accomplished through the interventions the youth worker employed when working with young people. Equally, challenges were highlighted relating to the youth worker undertaking their role in the hospital setting. However, changes during this time period in attitudes towards adolescent health particularly within the United Kingdom, along with the loss of funding for youth work has had an impact on the research in this area of clinical practice. The number of descriptive papers in this review, highlights the necessity for empirical evidence in both quantitative and qualitative research in order to gain a greater understanding of what the youth worker role in the hospital provides to young people and the impact of their interventions from the perspectives of young people, parents, youth workers and members of the multi-disciplinary team.

Addressing education and employment outcomes in the provision of healthcare for young people with physical long-term conditions: A systematic review and mixed methods synthesis

OBJECTIVE

To identify and synthesise the experiences and benefits of addressing vocational issues in the provision of healthcare for young people (YP) with long-term conditions (LTCs).

METHODS

We searched 10 bibliographic databases. Restrictions were applied on publication date (1996-2020) and language (English). Two reviewers independently screened records against eligibility criteria. Articles reporting relevant qualitative and/or quantitative research were included. Quality appraisal was undertaken following study selection. Qualitative data were synthesised thematically, and quantitative data narratively. A cross-study synthesis integrated qualitative and quantitative findings.

RESULTS

43 articles were included. Thematic synthesis of qualitative studies (n = 23) resulted in seven recommendations for intervention (psychological support; information/signposting; skills training; career advice; healthcare-school/workplace collaboration; social support; flexible/responsive care). The narrative synthesis summarised results of 17 interventions (n = 20 quantitative studies). The cross-study synthesis mapped interventions against recommendations. Transitional care was the intervention type that most comprehensively met our proposed recommendations.

CONCLUSIONS

Evidence from YP perspectives highlights that vocational development is an important area to address in healthcare provision. Robust intervention studies in this area are lacking.

PRACTICE IMPLICATIONS

Our evidence-based recommendations for intervention can support health professionals to better address vocational issues/outcomes. With minimal adaptations, transitional care interventions would be particularly well suited to deliver this.

Growing up with chronic pain: a systematic review of the evidence in transitional care for young people with chronic pain

Objective

Paediatric chronic pain presents a significant individual and societal burden, with an estimated prevalence of 11–38%. A large proportion of adolescents with chronic pain will have unresolved pain that continues into adulthood and thus requires transitional care. The aim of this review was to investigate the current evidence for the core components of effective transitional care interventions designed for young people with chronic pain.

Methods

Studies were identified by searching the Embase, MEDLINE, CINAHL and PsycINFO databases. A search strategy using terms such as ‘Adolescent’, ‘Persistent long-term pain’ and ‘Transition’ (or variations of such words) was implemented. Inclusion criteria were sample population age 10–24 years, a confirmed diagnosis of a condition characterized by chronic pain, any healthcare setting, any service provider, published peer reviewed and English language.

Results

Ninety-eight articles were identified by the search and 14 were selected after abstract screening. Two independent reviewers screened the articles, followed by a senior reviewer. Of the 14 articles, full-text review found that none of the articles looked specifically at evidence with respect to core components of effective transitional care designed for young people with chronic pain.

Conclusion

Chronic pain is a feature of many long-term health conditions. It remains unknown as to whether there are any pain-specific aspects of transitional care. How pain management is addressed in existing transitional care provision and the relationship of pain to outcomes needs further research. If effective interventions can be provided during these crucial years, the trajectory of these young people can potentially be improved into adulthood.

Effective transition of young people with long-term conditions into adult services

Healthcare transition involves the purposeful and planned process of preparing, empowering and supporting young people with long-term conditions and their families when they are moving from child to adult services. Transition is a series of events that provides the young person with the knowledge and skills they require to be able to function in adult services. Until recently little has been done to address the perceived barriers and challenges involved in transition. In this article, the authors discuss the challenges associated with effective transition and describe their experience of implementing a healthcare transition pathway using a quality improvement model.

But what do we mean by "health"? A critical perspective on the concept of health in the adolescent transition program of a Norwegian university hospital

BACKGROUND

To understand better what influences the practice of our transition program, we wanted to explore the underlying theory of health.

METHODS

We performed a qualitative content analysis of the written material that guides the program, comprising a quality system guideline, two checklists, a guide to health professionals and managers, and three patient brochures.

RESULTS

The analysis resulted in the formulation of three themes; "Being on top of medical management", "Ability to promote own health" and "Awareness of own goals and expectations".

CONCLUSION

Our analysis indicates that the program content revolves mainly around medical management and that other dimensions of health are not emphasised. We question what the goals of the program are and if these goals are explicit and shared among the program stakeholders. An explicit program theory is vital and needs to be evident in material supporting transition programs.

Hypertension in Children and Young Adults

Primary hypertension (PH) is most common during adolescence with increasing prevalence globally, alongside the epidemic of obesity. Unlike in adults, there are no data on children with uncontrolled hypertension and their future risk of hard cardiovascular and cerebrovascular outcomes. However, hypertension in childhood is linked to hypertensive-mediated organ damage (HMOD) which is often reversible if treated appropriately. Despite differing guidelines regarding the threshold for defining hypertension, there is consensus that early recognition and prompt management with lifestyle modification escalating to antihypertensive medication is required to ameliorate adverse outcomes. Unfortunately, many unknowns remain regarding pathophysiology and optimum treatment of childhood hypertension.

Active involvement of young people with T1DM during outpatient hospital consultations: Opportunities and challenges in transitional care services

OBJECTIVE

Little is known about active involvement of young people (YP) with type 1 diabetes (T1DM) in transitional care. This study aims to gain insight into patient-provider interactions during outpatient hospital consultations.

METHODS

Semi-structured observations (n = 61) of outpatient consultations with YP with T1DM (15-25 years) treated in 12 hospitals in the Netherlands. The consultations concerned pediatric care (n = 23), adult care (n = 17), and joint consultations (n = 21). Thematic data analysis focused on whether professionals engaged in open, in-depth conversations; used motivational interviewing techniques; involved YP in shared decision-making; and addressed non-medical topics.

RESULTS

Apart from some good examples, the healthcare professionals generally had difficulty interacting adequately with YP. They paid little attention to the YP's individual attitudes and priorities regarding disease management; non-medical topics remained generally underexposed. Conversations about daily life often remained shallow, as YP's cues were not taken up. Furthermore, decisions about personal and health-related goals were often not made together.

CONCLUSION

By adopting a more person-centered approach, professionals could empower YP to take an active role in their diabetes management.

PRACTICE IMPLICATIONS

Using a structured conversation model combined with a tool to encourage YP's agenda-setting and shared decision-making is recommended for more person-centered transitional care in T1DM.

Primary care service use during adolescence and young adulthood: Tertiary care cohort affected by chronic health conditions

OBJECTIVE

To understand use of family physician services and emergency department visits by adolescents and young adults with chronic health conditions.

DESIGN

Longitudinal retrospective observational cohort study using administrative health data.

SETTING

Chronic care clinics at a tertiary care pediatric hospital in Calgary, Alta.

PARTICIPANTS

In total, 1326 adolescents who were between 12 and 15 years old in 2008, who were observed until 2016, and who received medical services for chronic conditions were enrolled in the study. Eligible participants had at least 4 visits to the same chronic disease clinic in any 2-year window before age 18.

MAIN OUTCOMES MEASURES

Group-based trajectory modeling was used to identify groups of adolescents with distinct patterns of health care use (for visits to emergency departments and to primary care practices), while ² tests explored trajectory group differences (eg, sex, location of residence).

RESULTS

Median age was 14 years (range 12 to 17 years) at study entry, and 22 years (range 14 to 24 years) at study exit. Half were female and most (85.4%) lived in an urban area. Median observation period was 8.7 person-years (range 1.3 to 9.1 years). Group-based trajectory modeling identified 5 distinct trajectory groups of primary care use and 4 groups of emergency services use. Groups differed by sex and location of residence in each trajectory model.

CONCLUSION

Many adolescents increased their use of emergency services between the ages of 12 and 24 years, with distinct patterns of primary care use being observed. Association of additional patient- and system-level factors (eg, disease severity, distance to nearest family physician office) should be explored.

The role of Magnetic Resonance Images (MRIs) in coping for patients with brain tumours and their parents: a qualitative study

BACKGROUND

When children and young people (CYP) are diagnosed with a brain tumour, Magnetic Resonance Imaging (MRI) is key to the clinical management of this condition. This can produce hundreds, and often thousands, of Magnetic Resonance Images (MRIs).

METHODS

Semi-structured interviews were undertaken with 14 families (15 parents and 8 patients), and analysed using Grounded Theory. Analysis was supported by the Framework Method.

RESULTS

Although the focus of the research was whether paediatric patients and their families find viewing MRIs beneficial, all patients and parents discussed difficult times during the illness and using various strategies to cope. This article explores the identified coping strategies that involved MRIs, and the role that MRIs can play in coping. Coping strategies were classified under the aim of the strategy when used: 'Normalising'; 'Maintaining hope and a sense of the future'; 'Dealing with an uncertain future'; and 'Seeking Support'.

CONCLUSIONS

Coping and finding ways to cope are clearly used by patients and their families and are something that they wish to discuss, as they were raised in conversations that were not necessarily about coping. This suggests clinicians should always allow time and space (in appointments, consultations, or impromptu conversations on the ward) for patient families to discuss ways of coping. MRIs were found to be used in various ways: to maintain or adapt normal; maintain hope and a sense of the future; deal with an uncertain future; and seek support from others. Clinicians should recognise the potential for MRIs to aid coping and if appropriate, suggest that families take copies of scans (MRIs) home. Professional coaches or counsellors may also find MRIs beneficial as a way to remind families that the child is in a more stable or 'better' place than they have been previously.

“They Make Heavy Stuff Lighter.” Youth Workers in the Hospital Setting: A Service Evaluation

This article presents the findings of a service evaluation on the role of the youth worker offered to young people in the hospital setting across the United Kingdom and what differentiates the role of the youth worker from other health-care professionals, as described by young people, parents, and members of the existing multidisciplinary team. Young people, parents, and members of multidisciplinary teams were approached by a youth worker in the hospital regarding the purpose of the evaluation and the online survey relating to their views and experiences of working with a youth worker in the hospital setting. Data were analyzed descriptively. The n value represents the total number of responses: Young people 11-25 years (n = 47), mothers/fathers (n = 16), and members of the multidisciplinary team (n = 76). The findings suggested that the youth worker was highly valued by all, with a consensus that they had a positive impact on the experiences of young people, their parents, and members of the multidisciplinary teams. Youth workers were reported as offering a more relatable style of engagement that connected with young people on a different and more informal level than other members of the multidisciplinary team. Their approach to the support provided was also different as their focus was guided by what young people valued. Youth workers acted as the bridge between young people, their parents, and the multidisciplinary team and were considered by the multidisciplinary teams to be a fundamental ingredient when working with young people in the hospital setting. The findings from this evaluation provide unique insights into the role the youth worker offers to young people in hospital settings that is different from what other health-care professionals provide, as reported by young people, parents, and the multidisciplinary team. However, further evaluation of the service should include objective outcome measures of the role and in-depth qualitative research to gain a greater and more detailed understanding of young peoples', parents', and members of the multidisciplinary team's views and experiences of what makes this role different.

Facilitating transition of young people with long-term health conditions from children's to adults' healthcare services - implications of a 5-year research programme

BACKGROUND

During transition from children's to adults' healthcare, young adults with long-term conditions may show delays in psychosocial development compared to their peers without long-term conditions, and deterioration of their conditions' medical control.

METHODS

This paper integrates the findings, already published in 10 separate papers, of a 5-year transition research programme.

IMPLICATIONS

There is an important role for funders (commissioners) of adults' services to fund transitional healthcare, in addition to funders of children's services who currently take responsibility.It is important that healthcare provider organisations adopt an organisation-wide approach to implementation to ensure that good practice is adopted in children's and adults' services, not just adopted by enthusiasts in some specialties. This includes provision of 'developmentally appropriate healthcare' which recognises the changing biopsychosocial developmental needs of young people.Three features of transitional healthcare were associated with improved outcomes: appropriate parent involvement, promotion of young people's confidence in managing their health and meeting the adult team before transfer. These should be maintained or introduced as a priority.Child and adult healthcare providers should routinely explore with a young person how they approach transition and personalise their clinical approach thereafter.These implications are relevant for a range of stakeholders, including funders of transitional healthcare, organisations providing transitional healthcare and clinical practitioners.

Understanding the health-care experiences of people with sickle cell disorder transitioning from paediatric to adult services: This Sickle Cell Life, a longitudinal qualitative study

Background

Transitions from paediatric to adult health-care services cause problems worldwide, particularly for young people with long-term conditions. Sickle cell disorder brings particular challenges needing urgent action.

Objectives

Understand health-care transitions of young people with sickle cell disorder and how these interact with broader transitions to adulthood to improve services and support.

Methods

We used a longitudinal design in two English cities. Data collection included 80 qualitative interviews with young people (aged 13–21 years) with sickle cell disorder. We conducted 27 one-off interviews and 53 repeat interviews (i.e. interviews conducted two or three times over 18 months) with 48 participants (30 females and 18 males). We additionally interviewed 10 sickle cell disease specialist health-care providers. We used an inductive approach to analysis and co-produced the study with patients and carers.

Results

Key challenges relate to young people’s voices being ignored. Participants reported that their knowledge of sickle cell disorder and their own needs are disregarded in hospital settings, in school and by peers. Outside specialist services, health-care staff refuse to recognise patient expertise, reducing patients’ say in decisions about their own care, particularly during unplanned care in accident and emergency departments and on general hospital wards. Participants told us that in transitioning to adult care they came to realise that sickle cell disorder is poorly understood by non-specialist health-care providers. As a result, participants said that they lack trust in staff’s ability to treat them correctly and that they try to avoid hospital. Participants reported that they try to manage painful episodes at home, knowing that this is risky. Participants described engaging in social silencing (i.e. reluctance to talk about and disclose their condition for fear that others will not listen or will not understand) outside hospital; for instance, they would avoid mentioning cell sickle disorder to explain fatigue. Their self-management tactics include internalising their illness experiences, for instance by concealing pain to protect others from worrying. Participants find that working to stay healthy is difficult to reconcile with developing identities to meet adult life goals. Participants have to engage in relentless self-disciplining when trying to achieve educational goals, yet working hard is incompatible with being a ‘good adult patient’ because it can be risky for health. Participants reported that they struggle to reconcile these conflicting demands.

Limitations

Our findings are derived from interviews with a group of young people in England and reflect what they told us (influenced by how they perceived us). We do not claim to represent all young people with sickle cell disorder.

Conclusions

Our findings reveal poor care for young people with sickle cell disorder outside specialist services. To improve this, it is vital to engage with young people as experts in their own condition, recognise the legitimacy of their voices and train non-specialist hospital staff in sickle cell disorder care. Young people must be supported both in and outside health-care settings to develop identities that can help them to achieve life goals.

Future work

Future work should include research into the understanding and perceptions of sickle cell disease among non-specialist health-care staff to inform future training. Whole-school interventions should be developed and evaluated to increase sickle cell disorder awareness.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 44. See the NIHR Journals Library website for further project information.

Priorities and Outcomes for Youth-Adult Transitions in Hospital Care: Perspectives of Inpatient Clinical Leaders at US Children's Hospitals

OBJECTIVES

Adults with chronic conditions originating in childhood experience ongoing hospitalizations; however, efforts to guide youth-adult transitions rarely address transitioning to adult-oriented inpatient care. Our objectives were to identify perceptions of clinical leaders on important and feasible inpatient transition activities and outcomes, including when, how, and for whom inpatient transition processes are needed.

METHODS

Clinical leaders at US children's hospitals were surveyed between January and July 2016. Questionnaires were used to assess 21 inpatient transition activities and 13 outcomes. Perceptions about feasible and important outcome measures and appropriate patients and settings for activities were summarized. Each transition activity was categorized into one of the Six Core Elements (policy, tracking, readiness, planning, transfer, or completion). Associations between perceived transition activity importance or feasibility, hospital characteristics, and transition activity performance were evaluated.

RESULTS

In total, 96 of 195 (49.2%) children's hospital leaders responded. The most important and feasible activities were identifying patients needing or overdue for transition, discussing transition timing with youth and/or families, and informing youth and/or families that future stays would be at an adult facility. Feasibility, but not importance, ratings were associated with current performance of transition activities. Inpatient transition activities were perceived to be important for children with medical and/or social complexity or high hospital use. Emergency department visits and patient experience during transition were top outcome measurement priorities.

CONCLUSIONS

Children's hospital clinical leaders rated inpatient youth-adult transition activities and outcome measures as important and feasible; however, feasibility may ultimately drive implementation. This work should be used to inform initial research and quality improvement priorities, although additional stakeholder perspectives are needed.

Evaluation of an Educational and Vocational Service for Adolescent and Young Adults with Cancer: A Retrospective Review

Purpose: A cancer diagnosis and its treatment has the potential to interfere with the ability of adolescent and young adults (AYAs) to remain engaged in education or employment, placing social connectivity, career progression, and financial security at risk. This study aimed at assessing the educational and vocational outcomes of AYAs supported by an Education and Vocational Support Program (EVSP). Methods: Consecutive case files were reviewed of AYAs accessing the EVSP at ONTrac at Peter Mac (January 2014-December 2016). Data collected included: demographic information; diagnosis and treatment; referral time point; education/employment status at referral and end of treatment; and interventions provided. Results: Two hundred nineteen AYAs had >1 appointment with an EVSP advisor. The mean age was 19.6 (13-26). The most common intervention delivered was direct consultations. Overall, 79% of AYAs were engaged in educational and/or vocational pursuits at last known status. Engagement with EVSP during treatment for employment and tertiary educational support had a high rate of attendance at last known status (during treatment: 93% and 92.5%; post-treatment: 71% and 69%, respectively). At referral to EVSP, 27 AYAs were not in education, employment, or training; however, >50% re-integrated in employment or study after EVSP support. Conclusion: This is the first study to describe the role of an EVSP for Australian AYAs. With the support of an EVSP, the vast majority of AYAs remained engaged in education and/or employment throughout their cancer trajectory. Further research will be required to evaluate the quality of interventions and incorporate the voice of AYAs to further inform service delivery.

Shifting the mindset-adolescent and young adult rheumatology in transition

Almost 30 years have passed since publication of the first reports acknowledging the crucial importance of transitional care for adolescents and young adults with chronic disease, but universal implementation has yet to be achieved. Progress has undoubtedly been made, with increasing evidence for best practice in transitional care. However, translation of research and guidance into clinical practice continues to be challenging. Neuroscience advances in understanding the changes occurring in the adolescent brain demand that the third phase of transition (ie, post-transfer to adult services) is given further attention, with recognition that transfer itself is not the end of the transition process. The complex, often unwieldy health systems delivering care must also be considered. Paediatric and adult rheumatology practitioners need to collaborate not only with each other, but also with practitioners in other disciplines, specialties, and agencies, to plan and commission rheumatology services that are responsive to adolescents and young adults. A shift in approach from focusing on health transition towards developmentally appropriate health care has the potential to improve the care provided during this vulnerable life stage, increasing the likelihood of continuing engagement of patients in their own health care into adulthood and thereby improving health outcomes.

Clinician perspectives on the use of National Institute for Health and Care Excellence guidelines for the process of transition in Attention Deficit Hyperactivity Disorder

BACKGROUND

The UK National Institute for Health and Care Excellence (NICE) clinical guidelines recommends the following steps in the transition from child to adult services for young people with attention deficit hyperactivity disorder (ADHD): reassessment before and after transition, transition planning, formal meeting between services, and involvement from young person and carer, completed by age 18.

METHODS

A UK surveillance study asked clinicians to report young people on their caseloads with ADHD in need of transition to adult services in 2016 to support their continued access to medication need. Clinicians reported young people as they aged to within 6 months of the transition boundary, a prospective questionnaire prior to transition asked about intended transition and the use of local transition protocols. A retrospective questionnaire sent 9 months later established which steps recommended by NICE were followed during transition. Clinicians (38) working in child or adult services were interviewed about their experiences of transition and the use of NICE guidelines during transition and were analysed using a framework approach.

RESULTS

Information was shared between services in 85% of the 315 identified transition cases. A joint meeting was planned in 16% of cases; joint working before transfer occurred in 10% of cases. Clinicians were aware of NICE guidelines; they had mixed views on whether (local) guidelines or protocols were helpful. The main reason for not following guidelines was workload and resources: "NICE recommends stuff that is miles above what we will ever be able to provide".

CONCLUSIONS

Clinicians involved in the transition process of young people with ADHD judged NICE guidelines to be unrealistic given the current limited resources and service organization. More open dialogue is needed for recommendations on service models to bridge the gap between guideline recommendations and what is viewed as feasible and how implementation of guidance is funded, monitored, and prioritized. This may lead to valuable changes in the consultation process, for example, consideration of a layered (gold, standard, and minimal) system for some NICE guidelines.

Not being heard: barriers to high quality unplanned hospital care during young people's transition to adult services - evidence from 'this sickle cell life' research

Background

Young people’s experiences of healthcare as they move into adult services can have a major impact on their health, and the transition period for young people with sickle cell disease (SCD) needs improvement. In this study, we explore how young people with SCD experience healthcare during this period of transition.

Methods

We conducted a co-produced longitudinal qualitative study, including 80 interviews in 2016–2017 with young people with SCD aged 13–21 (mean age 16.6) across two cities in England. We recruited 48 participants (30 female, 18 male): 27 interviews were one-off, and 53 were repeated 2–3 times over approximately 18 months. We used an inductive analytical approach, combining elements of Grounded Theory and thematic analysis.

Results

Participants reported significant problems with the care they received in A&E during painful episodes, and in hospital wards as inpatients during unplanned healthcare. They experienced delays in being given pain relief and their basic care needs were not always met. Participants said that non-specialist healthcare staff did not seem to know enough about SCD and when they tried to work with staff to improve care, staff often seemed not prepared to listen to them or act on what they said. Participants said they felt out of place in adult wards and uncomfortable with the differences in adult compared with paediatric wards. Because of their experiences, they tried to avoid being admitted to hospital, attempting to manage their painful episodes at home and accessing unplanned hospital care only as a last resort. By contrast, they did not report having problems within SCD specialist services during planned, routine care.

Conclusions

Our study underscores the need for improvements to make services youth-friendly and youth-responsive, including training staff in SCD-specific care, compassionate care and communication skills that will help them elicit and act on young people’s voices to ensure they are involved in shaping their own healthcare. If young people are prevented from using transition skills (self-management, self-advocacy), or treated by staff who they worry do not have enough medical competency in their condition, they may well lose their trust in services, potentially compromising their own health.

Transitional Care in Rheumatology: a Review of the Literature from the Past 5 Years

PURPOSE OF REVIEW

Effective transitional care for adolescents and young adults (AYA) with rheumatic musculoskeletal disease (RMD) is fundamental to rheumatology care provision. Here we review the recent evidence from the literature on transition in rheumatology and debate why universal implementation has yet to be recognised.

RECENT FINDINGS

Evidence of need for transitional care continues to be reported. The triphasic nature of transitional care remains poorly recognised, and the third phase following transfer to adult rheumatology is particularly under-researched in spite of the recognition of the age-related trajectories of transition skill development during young adulthood. Several rheumatology-specific transitional care interventions have now been evaluated but the search for valid measures including outcome continues. Finally, the need to study transition at a health system level is increasingly recognised. Future research in this area should consider the developmental trajectories of AYA as well as the social-ecological model of transition readiness, which focuses on the interactions between AYA, caregivers and providers (and the systems they are part of) as these are the likely targets of any intervention to improve health transitions.

The impact of arthritis on the educational and early work experiences of young people: a qualitative secondary analysis

INTRODUCTION

Young people's transition into adulthood is intertwined with the worlds of education and work. Poor health in adolescence has been associated with poorer education and employment outcomes in adulthood. This paper explores the impact of arthritis on the educational and early work experiences of young people with arthritis.

METHODS

We undertook a supplementary secondary analysis of a qualitative dataset comprising narrative and semi-structured interviews of 39 young people who had been diagnosed with arthritis in childhood, adolescence or young adulthood.

RESULTS

Our findings illustrate how young people living with arthritis are faced with a range of added disruptions and challenges in their educational/vocational lives. There is an important element of resilience associated with the process of making a career choice and acting upon personal aspirations. Appropriate support and flexibility in the workplace/educational setting can enable successful outcomes, but disclosure is not a straightforward process for young people living with arthritis.

CONCLUSIONS

It is paramount that health providers consistently and effectively address self-advocacy skills with the young person, particularly during educational and vocational transitions. Alongside this, there is the need to further strengthen the health-school/work interface to ensure that young people living with chronic illness can meet their full potential in adulthood.

Pain Relief as a Motivation for Cannabis Use Among Young Adult Users With and Without Chronic Pain

This study aims to determine the rate of chronic pain in a community sample of young adult cannabis users, assess the extent to which pain relief is an important motivation for cannabis use, and explore differences in consumption patterns and problem behaviors between users with and without chronic pain. The study design was cross-sectional. Self-selected community-dwelling young adults (ages 18-29 years; n = 143) who regularly use cannabis completed an online survey. Results revealed that approximately 40% of the sample met the criteria for chronic pain, and pain relief was their primary motivation for use. There were no differences between groups with respect to frequency of use or estimated potency of their preferred strains; however, users with chronic pain reported using a wider variety of administration methods and a greater quantity of cannabis with each use. Users with chronic pain also reported more extensive histories of use, with younger age at initiation and longer duration of regular use. Despite riskier consumption patterns, there were no between-group differences in negative consequences owing to use after controlling for gender and educational status. On average, the total sample reported approximately 8 problems in the past 30 days owing to use. These findings suggest that chronic pain is commonly experienced among young adult cannabis users and pain relief is the primary motivation for users with pain. For some users, clinically significant chronic pain and pain-related interference persist despite heavy use. Cannabis users with and without chronic pain report experiencing several negative consequences owing to their use. PERSPECTIVE: This article compares motivations for cannabis use and describes differences in consumption patterns among a community sample of young adult users with and without chronic pain. This information may be useful for providers who assess and treat pain in young adults, particularly in settings that have legalized recreational use.

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.

Are we there yet? An update on transitional care in rheumatology

Significant progress has been made in the understanding of transitional care in rheumatology over the last few decades, yet universal implementation has not been realised and unmet needs continue to be reported. Possible explanations for this include lack of evidence as to which model is most effective; lack of attention to the multiple dimensions, stakeholders and systems involved in health transitions; and lack of consideration of the developmental appropriateness of transition interventions and the services/organisations/systems where such interventions are delivered.

Successful transition has major implications to both the young people with juvenile-onset rheumatic disease and their families. Future research in this area will need to reflect both the multidimensional (biopsychosocial) and the multisystemic (multiple systems and stakeholders across personal/social/family support networks and health/social care/education systems). Only then will we be able to determine which aspects of transition readiness and service components influence which dimension. It is therefore imperative we continue to research and develop this area, involving both paediatric and adult rheumatology clinicians and researchers, remembering to look beyond both the condition and our discipline. Neither should we forget to tap into the exciting potential associated with digital technology to ensure further advances in transitional care are brought about in and beyond rheumatology.