On Your Own Feet: A Practical Framework for Improving Transitional Care and Young People’s Self-Management
This chapter describes the lessons learnt from 10 years of the On Your Own Feet transitional care quality improvement programs in the Netherlands. It uses a framework that encompasses eight key elements of transitional care: youth participation, team collaboration, future-oriented, co-ordination, continuity of care, parent involvement, self-management, and psychosocial care. The framework distinguishes three core categories of interventions. The first aims at collaboration with young people (mirror meetings and independent consultations) and within multidisciplinary teams of professionals working in pediatric care and adult care (multidisciplinary team consultation meetings and shared vision). The second category aims at the organization of care (transition protocols or pathways, transition co-ordinators, and transition clinics). Interventions in the third category stimulate adolescents’ independence and self-management: individual transition plans (such as Ready Steady Go), parent group support, and routine measurement of quality of life. While evidence for the added value of these interventions is hard to find, they are valued by young people, parents, and professionals alike because they fit developmental needs and the principles of person-centered care. In our programs, nurses played a pivotal role as team leaders, designers, and implementers of transition interventions, and as connectors of pediatric and adult services.
KeywordsTransition in care Self-management Chronic conditions Quality improvement Team collaboration Continuity of care Adolescents Youth participation Parents Nursing
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