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Transitional Care

Nurses are integral to transitional care and function as transition co-ordinators to help breach between paediatric, adolescent and adult services.

Transition is ‘the purposeful, planned movement of adolescents with chronic physical and medical conditions from a child-centred to an adult-orientated healthcare system’, but also includes the transition from school to the workplace/higher education and also from home to independent living.

Transitional care starts early (from the age of 11 years), through transfer (usually 16-19 years) and continues into young adult years (up to 25 years) and needs to include generic health, mental health, disease specific issues and help young people develop self-advocacy and communication skills to function independently. Parents need help and support to ‘let go’.  

The EULAR / PReS 2016 recommendations for transitional care in rheumatology emphasise the importance of communication, flexibility for different model of care, transition co-ordinator roles and staff training to facilitate the optimal outcomes for young people. Evidence suggests that good transitional care leads to improved outcomes.

The ideal outcome of transitional care is that the young person is able to be assertive and communicate concerns to health care teams, take personal responsibility for their care and they are more likely to be independent young adults in the community. 

There are many resources to support health care teams to set up and deliver transitional care clinics.  These include:

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