Background It is well described that adolescents and parents find transition between the children's and adult ward challenging (1–2) because they feel inadequate prepared, and find communication and cultural differences between child and adult care challenging. Thus, transitional care programmes becomes essential for a successful process (3).
Objectives We aimed to develop a brief transition programme for adolescents with juvenile idiopathic arthritis (JIA), suitable for daily clinical practice in the children's and adult ward of rheumatology at Aarhus University Hospital, Denmark.
Methods The development was based upon studies of transitional care programmes and qualitative studies of the patient, parent, and health professionals perspective in the transition process. Needs in the transition process from the perspective of both adolescents and parents were further investigated through semi-structured interviews. We used studies by Janet McDonagh and colleagues (3) as a theoretical framework for the programme development.
Results The programme focuses on the final part of the transition process by including the adolescent from the children's ward at the age of 14. It runs for two years in the children's ward and continues the first year in the adult ward. The programme focuses on preparing the adolescent and parents for transition by enhancing the adolescent's knowledge and skills in coping with JIA. The programme further focuses on the relation between the adolescents and parents by bringing attention to the need for a gradually separation, and to placing more self-dependence on the adolescents. A guideline, describing the programme, containing concrete instructions to health professionals has been developed. The programme was primarily initiated by the adult ward, but nurses and physicians in both wards have been involved throughout the process.
The programme consists of the following elements;
Assigned contact persons.
Information leaflets about transitional care, transfer to adult care and differences between the children's and adult ward, i.e. in ways of working and treatment procedures.
Independent consultations with health professionals.
Materials for educational sessions.
Educational sessions dealing with JIA and treatment, dialogue on adherence and challenges in adolescence.
Arrangements of visits to the adult ward before transfer.
Conclusions Our experiences with the programme in practise are generally positive. However, we have experienced that successful implementation calls for good collaboration and continuous involvement of the health professionals involved in the programme on a daily basis. Hence, ongoing meetings and communication have been essential to promote collaboration between the children's and adult ward.
Shaw KL, Southwood TR, McDonagh JE. User perspectives of transitional care for adolescents with juvenile idiopathic arthritis. Rheumatology 2004; 43:770–78.
Reiss JG, Gibson RW, Walker LR. Health care transition: youth, family, and provider perspectives. Pediatrics 2005; 115:112–20.
McDonagh JE, Shaw KL, Southwood TR. Growing up and moving on in rheumatology: development and preliminary evaluation of a transitional care programme for a multicentre cohort of adolescents with juvenile idiopathic arthritis. J Child Health Care 2006; 10:22–42.
Disclosure of Interest None declared