Sustainable transition process for young people with chronic conditions: a narrative summary on achieved cooperation between paediatric and adult medical teams

Abstract

Background: Transfer of young people (YP) with chronic conditions to adult-centred multi-professional care (AdCC) has been discussed for decades. Generic principles for transition have been proposed, but resulting outcomes have not, on the whole, been documented and the burden of ensuring suitable transition continues to lie in the field of paediatrics. The emerging knowledge of the brain maturing into the twenties together with the enforced transfer of patients at 18.0 years of age has made paediatric clinics in Sweden reconsider their transition protocols.

Methods: Paediatrics-centred multi-professional care (PedCC) teams and AdCC teams in one administrative area participated in joint small group discussions on principles for transition during 2 days. The suggested principles were then given to next group in another administrative area for evaluation and elaboration. Thirteen such seminars with small group discussions took place consecutively.

Results: After this process, six core principles emerged as acceptable and essential. 1 The age of 18.0 was accepted as a reasonable age for the transfer of all patients from PedCC to AdCC. 2 A draft was developed of the knowledge and skills that PedCC should teach patients and parents before age 18, to make transfer viable. 3 A draft was made of the psychosocial needs of YP for the latter part of transition, which would be the responsibility of AdCC. 4 A self-referral note was developed, where patients present their own needs. 5 YP dropping out of needed care after transfer was considered a violation of ethical codes that required finite action. 6 Joint small group discussions between PedCC and AdCC were found to be instrumental for cooperation. Follow-up seminars demonstrated sustainability and spontaneous spreading of the principles.

Conclusion: Small group discussions between PedCC and AdCC were pivotal in creating a sustainable process for transition. It was possible to agree on six core principles and share the responsibility between PedCC and AdCC.