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The Importance of Being Earnest in Transitional Services

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Throughout childhood there is one team which deals with everything that the patient would need. As the children continue to grow, we wonder what will happen to them when they are too old to be cared for by the same team. So, what do we do with young patients who have been cared for very intimately by the paediatricians?

When they become adults, they could potentially find themselves thrown into a whole new world of healthcare which is not as homely, or as individualistic, as they would have experienced in the children’s services?

This particular demographic of patients faces plenty of challenges when transitioning to the complexity of adult life and, subsequently, adult responsibilities. Those individuals with complex physical and psychological health needs have additional difficulties in the road to transition. These needs would previously have been met by the same handful of individuals but, as they transition to the adult healthcare system, they will find themselves being transferred around multiple departments to provide them with the specialist care they require. 

The introduction of transitional processes should probably start early around the ages of 12 to 14 to allow for a period of discussion and acclimatisation to ensure greater confidence in services by the ages of 16 to 18. The time required depends entirely on the individual and the complexity of care required. Some young people can transfer almost immediately to adult services whereas others require years of transition to ensure the optimal manner of transfer.

Dr Jonathan Mamo

The process and team working on providing transitional services will differ from place to place. There will be qualified individuals responsible for ensuring the transition is as complete and as comprehensive as possible. There is no one definite system but each one works towards a common goal of providing a smooth and seamless “handover” of care from the Paediatrics team to Adult Health services.

All young people going through a process of transition should be provided with a written transition plan which would summarise and outline the key phases of the transition process. This should also have the names of the persons responsible for the specific aspects of the ongoing care needs. Should anyone not be sure of the process they are going through there will always be a main point of contact for clarification and explanation. 

Some services will provide site and process visits to allow young people to experience the travel to a service and the site of the service itself. In some situations, depending on availability, they may be able to meet with some of the teams who may be providing them with care in the future. 

Other aspects potentially covered could include medication as the young adult may be required to take on responsibilities including self-administration of medicines and treatments just as they would need to take on responsibilities in other areas of their lives.

The transition teams will also involve the parents or responsible adults in the transitional process as it would also take time for these responsible individuals to get to grips with the process of “letting go” of aspects of care which would previously have been their responsibilities.

The ultimate goal of any transition service is to ensure that the young person has all the skills and contacts available to ensure comfort and confidence in their transfer to adult health care services. This will feel somewhat like being “thrown” into a great unknown at time for all involved. The CQC had published a document with overviews and case studies of previous transition patients which is definitely worth a read by anyone going through this same process.

Just as the healthcare service plans to discuss transition early on, it would be ideal if families could have similar discussions at home around common themes such as;

  1. Learning the names and methods of taking medication, how much to take and asking the reason for taking the medication
  2. Seeing Health Care Professionals on their own for all or part of their clinic reviews
  3. Staying at hospital overnight on their own
  4. Monitoring hospital appointments
  5. Any questions around current and future healthcare needs
  6. How their condition may have impacts upon their lives in the future such as, for example, direct impacts on career, relationships, and intimacy.

It is essential that all people involved in the care of the young person, including the young person, should continue to ask questions around their care and to raise concerns with the relevant adult teams to ensure the best care going forward.

  • Dr Jonathan Mamo is a Consultant in Neurorehabilitation at Renovo Care South Newton. He is  also the Clinical Lead and Consultant for the Royal Berkshire Hospitals NHS Foundation Trust, Training Program Director for Health Education England Thames Valley and Clinical Panel Member for the Individual Funding Request Board for NHSE.

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