Transition Care Principles

Aim

The principles document for the transition of young people with chronic conditions from paediatric to adult care has been developed by the Agency for Clinical Innovation (ACI) Transition Executive Committee and Trapeze, a service of The Sydney Children’s Hospitals Network (SCHN), for use in the NSW Health system. The principles are evidenced based and aim to promote best practice for health professionals involved in caring for young people during transition. It is hoped that this document will assist LHDs and other related services to: a) establish transition processes and b) provide a plain English step by step guide to how to implement effective transition. The age range focuses on age 14-25 years.

Benefits

Despite agreement about the importance of effective transitional care, there is little evidence to inform best practice about both the process of and what constitutes effective transition.1

The ACI Transition Care Network and Trapeze believe that the implementation of, and adherence to, evidence-based principles will considerably improve the care and management of young people with chronic conditions transitioning from paediatric to adult health care including:

  • better functional outcomes including increased adherence, improved self-management and knowledge of condition, and improved wellbeing;
  • better access to appropriate health services for young people with a chronic condition;
  • improved morbidity and mortality rates; and
  • reduction in avoidable hospital admissions.

Summary

The principles for the transition of young people with chronic conditions from paediatric to adult care have been developed by the Agency for Clinical Innovation (ACI) Transition Executive Committee and Trapeze, a service of The Sydney Children’s Hospitals Network (SCHN), for use in the NSW Health system. The principles are evidenced based and aim to promote best practice for health professionals involved in caring for young people during transition. Despite agreement about the importance of effective transitional care, there is little evidence to inform best practice about both the process of and what constitutes effective transition1,2.

These principles are based on the evidence that has been evaluated in systematic reviews undertaken by Crowley, Wolfe Lock and McKee in 20113. and Kime, Bagnall and Day in 20134. The evidence correlates with that cited in key documents such as the NSW Youth Health Policy 2011-20165, the Transition Guidelines developed by the Royal Australasian College of Physicians6, and the Western Australian Paediatric Chronic Diseases Transition Framework7. The ACI Transition Care Network and Trapeze believe that the implementation of, and adherence to, evidence-based principles will considerably improve the care and management of young people with chronic conditions transitioning from paediatric to adult health care including:

  • better functional outcomes including increased adherence, improved self-management and knowledge of condition, and improved wellbeing;
  • better access to appropriate health services for young people with a chronic condition;
  • improved morbidity and mortality rates; and
  • reduction in avoidable unplanned hospital admissions.

Background

In 2009, there were nearly 4 million young people aged 12-24 in Australia (2.0 million males and 1.9 million females) representing 18% of the total population. Approximately 12% reported at least one chronic illness / disability8. Within Australia and globally, there is an increasing burden of chronic conditions. Young people with chronic conditions arising in childhood such as congenital cardiac disease, spina bifida and muscular dystrophy are contributing significantly with over 90% now estimated to survive into adulthood9.

As a consequence of this increase in survival, adolescents are transitioning at an increasing rate from paediatric services into mainstream adult services which are often ill equipped to meet their needs. Transition is defined as the purposeful planned movement of adolescents and young adults with chronic physical and medical conditions from child-centred to adult oriented health care systems10. There is increasing pressure to ensure a seamless transfer and transition from children’s to adult health care services in order to achieve improved health outcomes for young people.

Growing evidence suggests that young people with chronic conditions are doubly disadvantaged when they leave paediatric care11. Young people engage in risky behaviours at a rate at least similar if not higher than healthy peers, while having the potential for greater adverse health outcomes from these behaviours. For specific conditions such as diabetes there is increasing evidence of poorer outcomes for young people who disengage from health services. Indicators such as poor glycaemic control have been demonstrated12. along with increased rates of emergency presentations in hospitals and diabetes related complications13. There is also evidence that providing appropriate transition services can impact positively on the young person’s ability to manage their health and improve specific indicators such as HbA1C levels14.

Transitions principles are therefore vital for any health professional working with young people as they underpin the practices required for successful transition. Further, they guide and inform a health professional’s practice and act as the foundation for transition work.

Partnerships

The Principles Document for the transition of young people with chronic conditions from paediatric to adult care has been developed by the ACI Transition Executive Committee and Trapeze, a service of The Sydney Children’s Hospitals Network (SCHN), for use in the NSW Health system. It has been reviewed and ratified by the ACI Transition Care Executive Committee and will be tabled at ACI Executive.

Key Dates

Pilot Sites

Implementation Sites

Evaluation

Related Initiatives

Further Details

  1. Steinbeck KS, Brodie L, Towns S. ‘Transition to adult care in an Australian context’. Transition from Pediatric to Adult Medical Care. Wood D, Reiss J, Ferris M, Edwards L and Merrick J. New York Nova Science 2012
  2. While, A., Forbes, A., R. Ullman, S. Lewis, L. Mathes and P. Griffiths. 2004. Good practices that address continuity during transition from child to adult care: synthesis of the evidence. Child: care, health and development, 30, 439-452.
  3. Crowley R, Wolfe I, Lock K, McKee M. ‘Improving the transition between paediatric and adult healthcare: a systematic review’. Arch Dis Child; 2011; 96:548-553
  4. Kime N, Bagnall AM, Day R. Systematic review of transition models for young people with long term conditions: A report for NHS Diabetes. London 2013; NHS https://www.diabetes.org.uk/Documents/nhs-diabetes/paediatrics/systematic-review-transition-models-young-people-longterm-conditions.pdf
  5. NSW Department of Health. NSW Youth Health Policy 2011-2016: Healthy bodies, healthy minds, vibrant futures. NSW Department of Health, North Sydney 2010.
  6. Royal Australasian College of Physicians. Transition of Young People with Complex and Chronic Disability Needs from Paediatric to Adult Health Care. 2014 www.racp.edu.au
  7. Western Australian Government Child and Youth Health Network: Paediatric Chronic Diseases Transition Framework (2009). p 18
  8. Australian Institute of Health and Welfare. Young Australians, their Health and Wellbeing 2011. Cat No. PHE 140. AIHW, Canberra: http://www.aihw.gov.au/.
  9. Blum RW, Hirsch D, Kastner TA, Quint RD, Sandler AD. A Consensus Statement on health care transitions for young people with special health care needs. Pediatrics 2002;110: (6)1304-1306.
  10. Blum RW, Garell D, Hodgman CH, Jorissen TW, Okinow NA, Orr D et al. ‘Transition from child-centred to adult health-care systems for adolescents with chronic conditions- a position paper of the Society for Adolescent Medicine’. Journal of  Adolescent Health, 1993; 14: 570-57
  11. Sawyer SM, Drew S, Yeo MS, Britto MT.Adolescents with a chronic condition: challenges living, challenges treating’. Lancet 2007; 369: 1481–89.
  12. Fleming, E, Carter, B, Gillibrand, W. ‘The transition of adolescents with diabetes from the children’s health care service into the adult health care service: a review of the literature’. Journal of Clinical Nursing 2000; 11: 560-567.
  13. Nakhla M, Daneman D, To T, Paradis G, Guttmann, A. ‘Transition to adult care for youths with diabetes mellitus: findings from a universal health care system’. Paediatrics 2009; 124: e1134-e1141.
  14. Holmes-Walker DJ, Llewellyn AC, Farrell. ‘A transition care programme which improves diabetes control and reduces hospital admission rates in young adults with Type 1 diabetes aged 15–25 years’. Diabetic Medicine 2007; 24 (7): 764–769.

Contact

Lynne Brodie
Transition Care Network Manager
lynne.brodie@health.nsw.gov.au
02 9464 4617

Chris Shipway
Director, Primary Care and Chronic Services
chris.shipway@health.nsw.gov.au
02 9464 4603

Page Top | Added: 15 September 2014 | Last modified: 20 October 2014

ACI
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Contact:
Lynne Brodie
Transition Care Network Manager
Email
02 9464 4617
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