Transitional Care
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Date
2025-04-16
Citation
Gossens, L., Hackett, J., Rajabally, H. and Ammerlaan, J. (2025) ‘Transitional care’, in C. Ciurtin and J. Hackett (eds) Adolescent and Young Adult Rheumatology In Clinical Practice. Cham: Springer Nature Switzerland, pp. 325–344. Available at: https://doi.org/10.1007/978-3-031-82102-8_23.
Abstract
Transitional care continues to be a neglected area of practice in both adult and children’s services, with persisting confusion between the concepts of transition and transfer, often leading to unsatisfactory experiences and poorer long-term outcomes for adolescents and young adults (AYA). Unlike transfer, which is a one-off event, transitional care is a gradual, coordinated and developmentally appropriate, holistic approach, that not only prepares the young person for the eventual transfer to adult services, but attends to wider psychosocial aspects of their life, and other co-occurring transitions related to education, work, home life and other personal and culturally relevant transitions. Importantly, transitional care is person centred and responsive to the unique needs of the AYA which requires effective interpersonal skills, leadership, and flexibility on the part of the health provider, as well as robust policy and protocols. With permission, it also involves the young person’s care givers and supports them to develop their skills and knowledge in supporting AYA during this period. In practice, transitional care requires excellent multidisciplinary and multiagency teamwork, communication, and coordination, which should be planned and documented to ensure consistency with continued AYA support and skill development.
In this chapter we briefly outline key components of transitional care and how this might be implemented in a practice setting.