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The Multidisciplinary Transition Team

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Congenital Heart Disease and Adolescence

Part of the book series: Congenital Heart Disease in Adolescents and Adults ((CHDAA))

Abstract

The collective responsibility of transitioning youth with congenital heart disease (CHD) from pediatric to adult-focused care is shared by patients, their families, and members of their pediatric and adult health-care teams. In this chapter, we describe multidisciplinary collaboration (1) between pediatric and adult providers and (2) between various health-care professionals (nurses, physicians, and allied health professionals). For optimal outcomes, health-care providers should work together to send a uniform message to adolescents and young adults and their families, namely one that encourages increased health-care knowledge and self-management skills.

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References

  1. Gurvitz M, Saidi A (2014) Transition in congenital heart disease: it takes a village. Heart 100(14):1075–1076

    Article  CAS  PubMed  Google Scholar 

  2. Rearick E (2007) Enhancing success in transition service coordinators: use of transformational leadership. Prof Case Manag 12(5):283–287

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  4. Jessup RL (2007) Interdisciplinary versus multidisciplinary care teams: do we understand the difference? Aust Health Rev: a publication of the Australian Hospital Association 31(3):330–331

    Article  Google Scholar 

  5. Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A (2013) Ten principles of good interdisciplinary team work. Hum Resour Health 11:19

    Article  PubMed  PubMed Central  Google Scholar 

  6. American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine (2002) A consensus statement on health care transitions for young adults with special health care needs. Pediatrics 110(6 Pt 2):1304–1306

    Google Scholar 

  7. Wolfstadt J, Kaufman A, Levitin J, Kaufman M (2011) The use and usefulness of MyHealth Passport: an online tool for the creation of a portable health summary. Int J Adolesc Med Health 3(4):499–506

    Google Scholar 

  8. Kovacs AH, McCrindle BW (2014) So hard to say goodbye: transition from paediatric to adult cardiology care. Nat Rev Cardiol 11(1):51–62

    Article  PubMed  Google Scholar 

  9. Warnes CA, Williams RG, Bashore TM et al (2008) ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults with Congenital Heart Disease). Developed in Collaboration with the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 52(23):e1–e121

    Article  Google Scholar 

  10. Kieckhefer GM, Trahms CM (2000) Supporting development of children with chronic conditions: from compliance toward shared management. Pediatr Nurs 26(4):354–363

    CAS  PubMed  Google Scholar 

  11. Grandinette S (2014) Supporting students with brain tumors in obtaining school intervention services: the clinician’s role from an educator’s perspective. J Pediatr Rehabil Med 7(4):307–321

    PubMed  Google Scholar 

  12. McCurdy C, DiCenso A, Boblin S, Ludwin D, Bryant-Lukosius D, Bosompra K (2006) There to here: young adult patients’ perceptions of the process of transition from pediatric to adult transplant care. Prog Transplant 16(4):309–316

    Article  PubMed  Google Scholar 

  13. Prestidge C, Romann A, Djurdjev O, Matsuda-Abedini M (2012) Utility and cost of a renal transplant transition clinic. Pediatr Nephrol 27(2):295–302

    Article  PubMed  Google Scholar 

  14. Kovacs AH, Cullen-Dean G, Aiello S et al (2012) The Toronto congenital heart disease transition task force. Prog Ped Card 34:21–26

    Article  Google Scholar 

  15. Gleeson H, McCartney S, Lidstone V (2012) ‘Everybody’s business’: transition and the role of adult physicians. Clin Med 12(6):561–566

    Article  Google Scholar 

  16. Colver A, Longwell S (2013) New understanding of adolescent brain development: relevance to transitional healthcare for young people with long term conditions. Arch Dis Child 98(11):902–907

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kasinskas K, Colomb-Lippa D (2014) Congenital heart disease: transitioning from pediatric to adult cardiology care. JAAPA 27(8):32–34

    PubMed  Google Scholar 

  18. Mackie AS, Islam S, Magill-Evans J et al (2014) Healthcare transition for youth with heart disease: a clinical trial. Heart 100(14):1113–1118

    Article  PubMed  Google Scholar 

  19. Goossens E, Van Deyk K, Zupancic N, Budts W, Moons P (2014) Effectiveness of structured patient education on the knowledge level of adolescents and adults with congenital heart disease. Eur J Cardiovasc Nurs 13(1):63–70

    Article  PubMed  Google Scholar 

  20. Cullen-Dean G, Daniel K, Danziger J, Amaria K, Henze M, Kaufman K (2015) Transfer clinics: learning how to read your cards and how to play the game. J Adolesc Health 56(2, Suppl 1):S105–S106

    Google Scholar 

  21. Berg SK, Hertz PG (2007) Outpatient nursing clinic for congenital heart disease patients: Copenhagen Transition Program. J Cardiovasc Nurs 22(6):488–492

    Article  PubMed  Google Scholar 

  22. Saidi A, Kovacs AH (2009) Developing a transition program from pediatric- to adult-focused cardiology care: practical considerations. Congenit Heart Dis 4(4):204–215

    Article  PubMed  Google Scholar 

  23. Clarizia NA, Chahal N, Manlhiot C, Kilburn J, Redington AN, McCrindle BW (2009) Transition to adult health care for adolescents and young adults with congenital heart disease: perspectives of the patient, parent and health care provider. Can J Cardiol 25(9):e317–e322

    Article  PubMed  PubMed Central  Google Scholar 

  24. Suris JC, Akre C, Rutishauser C (2009) How adult specialists deal with the principles of a successful transition. J Adolesc Health 45(6):551–555

    Article  PubMed  Google Scholar 

  25. Amaria K, Stinson J, Cullen-Dean G, Sappleton K, Kaufman M (2011) Tools for addressing systems issues in transition. Healthc Q 14 Spec No 3:72–76

    PubMed  Google Scholar 

  26. Suris JC, Akre C (2015) Key elements for, and indicators of, a successful transition: an international Delphi study. J Adolesc Health 56(6):612–618

    Article  PubMed  Google Scholar 

  27. Mennito S (2012) Resident preferences for a curriculum in healthcare transitions for young adults. South Med J 105(9):462–466

    Article  PubMed  Google Scholar 

  28. Hess JS, Straub DM, Mateus JS, Pelaez-Velez C (2015) Preparing for transition from pediatric to adult care: evaluation of a physician training program. Adv Pediatr 62(1):137–164

    Article  PubMed  Google Scholar 

  29. Olsen DG, Swigonski NL (2004) Transition to adulthood: the important role of the pediatrician. Pediatrics 113(3 Pt 1):e159–e162

    Article  PubMed  Google Scholar 

  30. Marino BS, Lipkin PH, Newburger JW et al (2012) Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation 126(9):1143–1172

    Article  PubMed  Google Scholar 

  31. Brosig C, Yang K, Hoffmann RG, Dasgupta M, Mussatto K (2014) The role of psychology in a pediatric outpatient cardiology setting: preliminary results from a new clinical program. J Clin Psychol Med Settings 21(4):337–346

    Article  PubMed  Google Scholar 

  32. Kovacs AH, Silversides C, Saidi A, Sears SF (2006) The role of the psychologist in adult congenital heart disease. Cardiol Clin 24(4):607–618, vi

    Article  PubMed  Google Scholar 

  33. Bromberg JI, Beasley PJ, D’Angelo EJ, Landzberg M, DeMaso DR (2003) Depression and anxiety in adults with congenital heart disease: a pilot study. Heart Lung 32(2):105–110

    Article  PubMed  Google Scholar 

  34. Kovacs AH, Saidi AS, Kuhl EA et al (2009) Depression and anxiety in adult congenital heart disease: predictors and prevalence. Int J Cardiol 137(2):158–164

    Article  PubMed  Google Scholar 

  35. Gurvitz MZ, Inkelas M, Lee M, Stout K, Escarce J, Chang RK (2007) Changes in hospitalization patterns among patients with congenital heart disease during the transition from adolescence to adulthood. J Am Coll Cardiol 49(8):875–882

    Article  PubMed  Google Scholar 

  36. Wray J, Frigiola A, Bull C (2013) Loss to specialist follow-up in congenital heart disease; out of sight, out of mind. Heart 99(7):485–490

    Article  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, 585 University Ave, 5 N-523, Toronto, ON, M5G 2N2, Canada

    Adrienne H. Kovacs

  2. Good 2 Go Transition Program, Hospital for Sick Children, Toronto, ON, Canada

    Geraldine Cullen-Dean

  3. Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA

    Luke J. Burchill

  4. Department of Pediatrics, University of Florida, Gainesville, FL, USA

    Arwa Saidi

Authors
  1. Adrienne H. Kovacs
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  2. Geraldine Cullen-Dean
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  3. Luke J. Burchill
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  4. Arwa Saidi
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Corresponding author

Correspondence to Adrienne H. Kovacs .

Editor information

Editors and Affiliations

  1. Center for Congenital Heart Disease, University Hospital Inselspital, Bern, Switzerland

    Markus Schwerzmann

  2. Center for Congenital Heart Disease, University Hospital Inselspital, Bern, Switzerland

    Corina Thomet

  3. Department of Public Health and Primary Care, KU Leuven – University of Leuven, Leuven, Belgium and Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden

    Philip Moons

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© 2016 Springer International Publishing Switzerland

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Kovacs, A.H., Cullen-Dean, G., Burchill, L.J., Saidi, A. (2016). The Multidisciplinary Transition Team. In: Schwerzmann, M., Thomet, C., Moons, P. (eds) Congenital Heart Disease and Adolescence. Congenital Heart Disease in Adolescents and Adults. Springer, Cham. https://doi.org/10.1007/978-3-319-31139-5_13

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  • DOI: https://doi.org/10.1007/978-3-319-31139-5_13

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-31137-1

  • Online ISBN: 978-3-319-31139-5

  • eBook Packages: MedicineMedicine (R0)

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