TRANSITION POLICY final - agreed team meeting Feb 2014 – due revision Feb 2015

Transition Policy for young people transferring from Rheumatology services in Sheffield Children’s Hospital to the Young Adult Rheumatology Clinic, Sheffield Teaching Hospitals

Introduction

Sheffield Childrens Hospital (SCH) provides routine care for children and young people (CYP) to the ages of 16-18 and occasionally beyond. CYP with chronic rheumatological disease need to transfer from paediatric to adult services at an individually developmentally-appropriate point and in the context of a well-planned and documented process of transition.

Transition is the multi-faceted, active process that attends to the medical, psychological and educational/vocational needs of adolescents as they move from child to adult-centred care

A summary of current evidence for the need for transition, best practice models and policy drivers is attached in appendix A and a summary of the principles of adolescent health care in appendix B. This policy outlines local arrangements for transition and transfer in Sheffield. A guiding principle is that young people should always be engaged in choices about their care and seen in dedicated young peoples’ clinics (YPC).

The Team

SCH / STH
Consultant / Anne-Marie Mcmahon
()
Dan Hawley
()
Muthana Al-Obaidi
() / Rachel Tattersall
()
Clinical Nurse Specialists / Jenny Edgerton
Helen Lee
Sam Bull
()
Giselle Cooper (uveitis nurse)
/ Maria Forsythe
()
Jayne Mcdermott (CTD)
()
Pauline Mark (TNFi service)
()
Physio-therapy / Sam Leach
()
Oliver Ward
() / Zoe Cox
()
Occup-ational Therapists / Michelle Loveley
() / Ruth Larder
()
Dervil Dockrell
(
Secretary / Tracy Rew
() / Kate Hardy
()
Pharmacy / Clare Nash
() / Aini Alcock
()
Psychology / Rachel Horne
() / Jane Royle
()

Outline of Transitional Services

*all patients on biologic drugs over age 16 to have shared care between SCH/STH as safety mechanism in context of immune suppression and need to attend adult A&E out of hours

Supporting Transition/Transfer Documentation (see Appendix C)

·  Patient information regarding transition

o  STH generic ‘what to expect’ transition leaflet

o  SCH rheumatology specific transitional leaflet

·  Annual transition checklist

o  To be completed with young people during their appointment at least once per year from 14-16

·  Transfer Document

·  Excel spreadsheet of patients in transitional clinic, stage of transition and documentation of successful transfer – held and updated by SCH CNS


Ongoing Service Evaluation

·  Policy and supporting documentation to be reviewed every 2 years

·  Annual audit to ensure compliance with pathway

Aspirations

·  Transition specific research programme to be devised

·  Liaison with other services

o  Gastroenterology – Dr Priya Narula

o  Dermatology – Professor Andrew Messenger/Dr Michael Cork

o  Immunology – Dr Fiona Shackley

o  Ophthalmology – Miss Jessy Choi

Appendix A

Tattersall RS, McDonagh JE 2010 Transition: A rheumatology perspective BJHM 71 315-319

McDonagh JE 2008 Young people first juvenile idiopathic arthritis second: transitional care in rheumatology Arthritis & Rheumatism (Arthritis Care and Research) 59 1162-70

Appendix B

copies of all documents

·  Transition checklist

·  Transfer document

·  STH Leaflet

·  SCH Leaflet

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