Alström Team Transitional Care

‘Best Journey to Adulthood’

Marie McGeeTransition Care Co-ordinator

Rheumatology Department, BCHmarie.mcgee@bch.nhs.uk

What is Transition?“Transition is the purposeful, planned movement of adolescents

and young adults with chronic physical and medical conditions from

child-centred to adult-orientated health care systems.”(Blum et al, 1993)

In healthcare, we use the word 'transition' to describe the process of preparing and planning the move from children’s (paediatric) to adult services

It is a gradual process that gives the YP, their family and anyone involved in the individuals care, time to plan the move to adult services and discuss what healthcare/ lifestyle needs will be required

Myths and Facts!Myth – transition is a one off event

FACT – transition is a well planned, process which needs a multi disciplinary, interagency, holistic approach

Myth – transition is a fixed programme

FACT - transition is a flexible process based on individual needs

Myth- transfer is the same as transition

FACT - transfer is the actual movement of the young person/family and their health records over to adult services

Poor Experiences of Transition and Transfer

Dumped

Abandoned Thrown out

Cut offSudden

Tossed out

Shaw KL, Southwood TR, McDonagh JE 2004

Not prepared

Lack ofinformation

Transition

Transition plans start at around age 11

Check list of questions- lead to wider conversations

Variety of communication styles

Suit a variety of needs e.g. VI-LD

Builds young peoples independence and confidence

Improves young peoples skills and knowledge with their healthcare

Prepares the young person and their family for transfer

My Health-My Life! Transition Plans

Transition Gateway 1 -–Set Up! (11-13)

Transition Gateway 2– Get Up! (13-15)

Transition Gateway 3-Go! (15-18)

Transition Gateway 4-Transfer (16 onwards)

Each young person is an individual

 

 

My Health-My Life! Transition Plans

•Learning Difficulties Plans

•Budget Plans- planning direct payments and individualised budgets

•Parent/Carer Plans

Every family requires different types of support

 

 

•Young people are active participants

•Involve parents/carers

•Starts early with a holistic approach

•Transition is a gradual process

•Transition should result in a well planned transfer to adult services

•Multi disciplinary/inter agency team around the family

•Your views are important to us-