Transitions of Care Flashcards
Which types of patients are we mainly referring to when discussing pediatric to adulthood transition of care?
youth with special care needs
-physical developmental, and/or mental health conditions
-complex care
-chronic conditions
-psychosocial risk
-significant caregiver involvement
What is transition of care?
purposeful and planned process of moving from pediatric to adult care services beginning in adolescence and continuing into early adulthood
What are the differences between pediatric and adult care?
pediatric:
-caregiver involvement
-family oriented
-interdisciplinary
-psychosocial function
adult:
-independence
-managing medications
-self advocacy
-informed decision making
Why does having a transition plan matter?
15-18% North American youth live with a chronic health condition
poor health outcomes
caregiver burden (substitute decision maker)
mental health (vulnerable to declining mental health)
disengagement
What are the recommendations from the Canadian Pediatric Society on transitions of care?
- ensure care is continuous, and meets needs of all involved
- prepare youth gradually, timing is individualized (flexible age cut-offs)
- collaboration between pediatric and adult care providers
- establish ‘quality indicators’ of successful transition
- educational reforms for youth, families, and HCPs
- appropriate program funding
What are the recommendations from Ontario Health on transitions of care?
- early identification and transition readiness
- information sharing and support
- transition plan
- coordination transition
- introduction to adult services
- transfer completion
What are the recommendations from SickKids regarding pediatric involvement in their own care?
very early (<10):
-learn name of medications
-medication administration
early (10-13):
-appointment scheduling
middle (14-16):
-drug coverage changes
late (17-18):
-consolidation of health information
What are the barriers to transition?
difficulty navigating healthcare system
shift from holistic, interdisciplinary care to fragmented care
difficulty finding a primary care provider to coordinate care
shift in responsibility
‘fear of unknown’ for patients and family
financial barriers
What are the barriers to transition from a pediatric perspective?
adult HCP lack of specialized knowledge
difficult to establish new relationships
feelings of abandonment, grieving
adult HCP less inclined to ‘listen’
reduced time for appointments
adult HCP less personable
What are the consequences of the barriers to transition?
decreased clinical engagement
increased ED use
increased hospitalizations
poor clinical outcomes
What is a transition champion?
a clinician who takes responsibility for facilitating and coordinating the HCPs involved a young persons care, including primary care, and ensuring effective communication throughout the process
How can we assess transition readiness?
validated self-assessment tools for adolescents with chronic disease to assess readiness to transition to adult care
-TRANSITION-Q, Am I ON TRAC
What is the issue with transition outcomes?
lack of generalizability, consensus how a successful transition is defined and measured
What is the pharmacists role in transition of care?
navigating insurance, support programs
where/how to obtain prescription refills
establishing goals of therapy
educating on ‘self-care’
medication education
bridge between pediatric and adult services
accessible
