Skip to main content
SpringerLink
Log in

Measurable Outcomes for Transition: The Nurses’ Role

  • Chapter
  • First Online:
Transition from Pediatric to Adult Healthcare Services for Adolescents and Young Adults with Long-term Conditions

Abstract

This chapter highlights the importance of the role of the nurse in monitoring and tracking transition-related outcomes both pre- and post-transfer of care. Nurses play a vital role in educating adolescents and young adults (AYA) about their healthcare condition, including how to manage their condition for optimal outcomes. Additionally, nurses prepare youth for transition supporting them pre- and post-transition. Important outcomes to monitor include self-management and treatment adherence, healthcare planning, disease specific outcomes, healthcare utilization, and quality of life (QOL). Nurses, prior to transfer, have essential roles in preparing AYA for self-management of their healthcare needs. Nurses can help AYA develop the knowledge and skills needed for self-management, while monitoring and tracking treatment adherence. Additionally, nurses are ideally suited to assist AYA and their families with planning for the transition while monitoring readiness for the transfer of care. Disease specific outcomes and healthcare utilization are important to monitor both before transfer (as baseline data) and after transfer to determine the success of the transition. Finally, measuring and tracking QOL is essential. In summary, nurses can assist in tracking and monitoring outcome measures to evaluate the extent to which the healthcare transition has achieved expected outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 59.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002;110(Supplement 3):1304–6.

    Google Scholar 

  • American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, et al. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011;128(1):182–200.

    Article  Google Scholar 

  • Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns. 2002;48(2):177–87.

    Article  PubMed  Google Scholar 

  • Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759–69.

    Article  Google Scholar 

  • Betz CL. Adolescent transitions: a nursing concern. Pediatr Nurs. 1998;24(1):23–8.

    Google Scholar 

  • Betz CL. SPN position statement: transition of pediatric patients into adult care. J Pediatr Nurs. 2017;35:160–4.

    Article  PubMed  Google Scholar 

  • Betz CL, Redcay G. Dimensions of the transition service coordinator role. J Spec Pediatr Nurs. 2005;10(2):49–59.

    Article  PubMed  Google Scholar 

  • Betz CL, Ferris ME, Woodward JF, Okumura MJ, Jan S, Wood DL. The health care transition research consortium health care transition model: a framework for research and practice. J Pediatr Rehabil Med. 2014;7(1):3–15.

    Article  PubMed  Google Scholar 

  • Bloom SR, Kuhlthau K, Van Cleave J, Knapp AA, Newacheck P, Perrin JM. Health care transition for youth with special health care needs. J Adolesc Health. 2012;51(3):213–9.

    Article  PubMed  Google Scholar 

  • Blum RW, Garell D, Hodgman CH, Jorissen TW, Okinow NA, Orr DP, Slap GB. Transition from child-centered to adult health-care systems for adolescents with chronic conditions: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 1993;14(7):570–6.

    Article  CAS  PubMed  Google Scholar 

  • Coyne B, Hallowell SC, Thompson M. Measurable outcomes after transfer from pediatric to adult providers in youth with chronic illness. J Adolesc Health. 2017;60(1):3–16.

    Article  PubMed  Google Scholar 

  • Diiorio C, McCarty F, DePadilla L, Resnicow K, Holstad MM, Yeager K, Sharma SM, Morisky DE, Lundberg B. Adherence to antiretroviral medication regimens: a test of a psychosocial model. AIDS Behav. 2009;13(1):10–22.

    Article  PubMed  Google Scholar 

  • Erikson E. Psychological issues. New York: International Universities Press; 1959.

    Google Scholar 

  • Fair C, Cuttance J, Sharma N, Maslow G, Wiener L, Betz C, Porter J, McLaughlin S, Gilleland-Marchak J, Renwick A, Naranjo D. International and interdisciplinary identification of health care transition outcomes. JAMA Pediatr. 2016;170(3):205–11.

    Article  PubMed  PubMed Central  Google Scholar 

  • Garvey KC, Wolpert HA, Rhodes ET, et al. Health care transition in patients with type 1 diabetes: young adult experiences and relationship to glycemic control. Diabetes Care. 2012;35(8):1716–22. https://doi.org/10.2337/dc11-2434.

    Article  PubMed  PubMed Central  Google Scholar 

  • Grivetta SA, Gilot CB, Coggiola M, Mignone F, Silvestro E, Orofino G, Altini P, Di Chio C, Gabiano C. HIV positive youth’s healthcare transition from pediatric to adult service: nursing implications. Child Nurs. 2012;4(3):98–101.

    Google Scholar 

  • Health Resources and Services Administration Maternal and Child Health. 2016. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs#ref1. Accessed 11 July 2018.

  • Johnson SB, Blum RW, Giedd JN. Adolescent maturity and the brain: the promise and pitfalls of neuroscience research in adolescent health policy. J Adolesc Health. 2009;45(3):216–21.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kipps S, Bahu T, Ong K, Ackland FM, Brown RS, Fox CT, Griffin NK, Knight AH, Mann NP, Neil HA, Simpson H. Current methods of transfer of young people with type 1 diabetes to adult services. Diabet Med. 2002;19(8):649–54.

    Article  CAS  PubMed  Google Scholar 

  • Korus M, Stinson JN, Pool R, Williams A, Kagan S. Exploring the information needs of adolescents and their parents throughout the kidney transplant continuum. Prog Transplant. 2011;21(1):53–60.

    Article  PubMed  Google Scholar 

  • Lawson EF, Hersh AO, Applebaum MA, Yelin EH, Okumura MJ, von Scheven E. Self-management skills in adolescents with chronic rheumatic disease: a cross-sectional survey. Pediatr Rheumatol. 2011;9(1):35.

    Article  Google Scholar 

  • Lotstein DS, Seid M, Klingensmith G, Case D, Lawrence JM, Pihoker C, Dabelea D, Mayer-Davis EJ, Gilliam LK, Corathers S, Imperatore G. Transition from pediatric to adult care for youth diagnosed with type 1 diabetes in adolescence. Pediatrics. 2013;131:e1062–70.

    Article  PubMed  PubMed Central  Google Scholar 

  • Mackie AS, Islam S, Magill-Evans J, Rankin KN, Robert C, Schuh M, Nicholas D, Muhll IV, McCrindle BW, Yasui Y, Rempel GR. Healthcare transition for youth with heart disease: a clinical trial. Heart. 2014;100:1113–8.

    Article  PubMed  Google Scholar 

  • McDonagh JE, Hackett J. Growing up in school with a chronic condition. Br J School Nurs. 2008;3(8):385–92.

    Article  Google Scholar 

  • McHorney CA, Ware JE Jr, Lu JR, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40–66.

    Article  CAS  PubMed  Google Scholar 

  • Miller VA, Drotar D. Decision-making competence and adherence to treatment in adolescents with diabetes. J Pediatr Psychol. 2006;32(2):178–88.

    Article  PubMed  Google Scholar 

  • National Research Council. The science of adolescent risk-taking: workshop report. Washington: National Academies Press; 2011.

    Google Scholar 

  • Prior M, McManus M, White P, Davidson L. Measuring the “triple aim” in transition care: a systematic review. Pediatrics. 2014;134(6):e1648–61.

    Article  PubMed  Google Scholar 

  • Roebroeck ME, Jahnsen R, Carona C, Kent RM, Chamberlain MA. Adult outcomes and lifespan issues for people with childhood-onset physical disability. Dev Med Child Neurol. 2009;51(8):670–8.

    Article  PubMed  Google Scholar 

  • Sawicki GS, Lukens-Bull K, Yin X, Demars N, Huang IC, Livingood W, Reiss J, Wood D. Measuring the transition readiness of youth with special healthcare needs: validation of the TRAQ—Transition Readiness Assessment Questionnaire. J Pediatr Psychol. 2009;36(2):160–71.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sawin KJ, Cox AW, Metzger SG, Horsley JW, Harrigan MP, Deaton A, Thompson EC. Transition planning for youth with chronic conditions: an interdisciplinary process. Nat Acad Pract Forum. 1999;1(3):183–96.

    Google Scholar 

  • Sawyer SM, Drew S, Yeo MS, Britto MT. Adolescents with a chronic condition: challenges living, challenges treating. Lancet. 2007;369(9571):1481–9.

    Article  PubMed  Google Scholar 

  • Stinson J, Wilson R, Gill N, Yamada J, Holt J. A systematic review of internet-based self-management interventions for youth with health conditions. J Pediatr Psychol. 2008;34(5):495–510.

    Article  PubMed  Google Scholar 

  • Suris JC, Akre C. Key elements for, and indicators of, a successful transition: an international Delphi study. J Adolesc Health. 2015;56(6):612–8.

    Article  PubMed  Google Scholar 

  • White PH, Cooley WC, American Academy of Pediatrics, American Academy of Family Physicians. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2018;142(5):e20182587.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Family, Community & Mental Health Systems, University of Virginia School of Nursing, Charlottesville, VA, USA

    Bethany Coyne

  2. University of Lynchburg, Lynchburg, VA, USA

    Sara C. Hallowell

Authors
  1. Bethany Coyne
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sara C. Hallowell
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bethany Coyne .

Editor information

Editors and Affiliations

  1. Keck School of Medicine, Department of Pediatrics, University of Southern California, Los Angeles, CA, USA

    Cecily L. Betz

  2. School of Nursing and Midwifery, Faculty of Health Sciences, Trinity College, Dublin, Ireland

    Imelda T. Coyne

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Coyne, B., Hallowell, S.C. (2020). Measurable Outcomes for Transition: The Nurses’ Role. In: Betz, C., Coyne, I. (eds) Transition from Pediatric to Adult Healthcare Services for Adolescents and Young Adults with Long-term Conditions. Springer, Cham. https://doi.org/10.1007/978-3-030-23384-6_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-23384-6_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-23386-0

  • Online ISBN: 978-3-030-23384-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation