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| Transition Toolkit |
>>  (2010-01-08 12:26:50) |
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The information on this page is designed to assist both new staff to the rheumatology unit at Birmingham Children’s Hospital as well as rheumatology colleagues elsewhere, to facilitate effective transition for their adolescent patients requiring transfer to adult health care. What is Transition? Healthcare transition has been defined as a multi-dimensional active process that attends to the medical, psychosocial and educational/vocational needs of adolescents as they move from child to adult centred care. What are the aims of transition? 2. To promote skills in communication, decision-making, assertiveness, self-care, self-determination and self-advocacy; 3. To enhance sense of control and interdependence in healthcare 4. To maximize life-long functioning and potential 5. To support the parent(s)/guardian of the young person during transition and in particular to enhance their advocacy skills
What are the Top 10 components of the DREAM team transitional care programme at The DREAM team project was established to translate the research findings of the first ever trial of transitional care in any chronic illness into NHS clinical practice. The original research (DreamTeam research) was directed by Dr McDonagh on behalf of the British Society of Paediatric and Adolescent Rheumatology (www.bspar.org.uk) and reported that the health related quality of life, disease-related knowledge, patient satisfaction and vocational readiness could be improved by a transitional care programme. The latter was evidence based, developed by Drs McDonagh and Shaw in response to the first phase of the project which had revealed a wide range of unmet needs with respect to young people with juvenile idiopathic arthritis, their parents and the professionals involved in their care. The programme was specifically designed to meet these needs. The Top 10 components are: 1. A Departmental transition policy This policy uses the BCH hospital generic template and includes a major educational component in view of the unmet training needs in this area (Transition Policy 2006). This is sent to all specialties and ward areas we share patients with and to the adult rheumatologists with whom we transfer young people to within the 2. Information Leaflets for young people and their parents about transition. 3. Transition Checklists These checklists have been developed from research conducted in a large multicentre study involving over 300 teenagers and their parents (McDonagh et al 2006). They are designed for self completion by the young person themselves and then used as an education tool to help prepare young people with the necessary skills to take charge of their own health care and to negotiate the adult health care system themselves.
Resource list for transition planning for parents
4. A Multidisciplinary Team MDT Transition Plan to coordinate transition Once transitional issues have been identified by the young person on the checklists, these are addressed and assessed during consecutive outpatient visits by team members, and the MDT Transition plans updated following each clinic. (purple template) Documentation of relevant information is vital in view of both the multidimensional and multidisciplinary nature of transitional care. Once the young person is competent in the transitional skills addressed in the checklist, they then complete the next checklist and preparation continues in a gradual age and developmentally appropriate manner (transition pathway). 5. Inclusion of transitional care planning in letters to other professionals To further facilitate coordination, transitional care issues are detailed in the letter sent to the referring doctor with a copy sent to the young person in agreement with government strategy (Department of Health learning reource) 6. Informational and signposting resources for young people and their parents Information for young people and their parents about medical, psychosocial, educational and vocational aspects of transition including other relevant service providers can be found on this website. A summary of resources available in the clinic waiting area can be found here (resource list 2009). A monthly e-newsletter edited by Dr McDonagh provides an ongoing update of the resource database (newsletters). A resource list for parents can be found here for use with the transition planning checklist for parents. 7. Transfer documentation The Transfer Summary Record is a document to use when transferring any young person to adult care. This document aims to:
8. The Please see the Adult Services pages of this website. 9. Training Useful tools for new staff include the Adolescent HEADS screening tool and a list of trigger questions for consultations. Interested health professionals can gain further training via the Adolescent health e-learning project http://e-lfh.org.uk/projects/ah/index.html Further training opportunities can be found in the professionals section and including the monthly e-newsletters
10. Regular Audit of service As well as feedback being encouraged on this website, (please contact janet.mcdonagh@bch.nhs.uk) the following tools are used within the department to audit our service:
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