Table 1 Transitional care models for Autoimmune Rheumatic Patients in Western Countries [16, 17]
From: Autoimmune rheumatic transitional care model development
Programme | Country | Setting | Diseases | Age (year) | Age of Transition (year) | Transition Coordinator | Transition Team Staff | Strategy and Tools | Indicators | Results |
|---|---|---|---|---|---|---|---|---|---|---|
Clinical transition pathway for adolescents with juvenile-onset rheumatic and musculoskeletal diseases | Netherland | Erasmus University Medical Centre Rotterdam | Childhood onset Rheumatic Musculoskeletal Diseases (RMD) | 17–18 | 17.8 | Yes | Pediatric & adult Rheumatologist, nurse, other | Not specified | Drop out rate Disease activity: number of tender &swollen joints Erythrocyte Sedimentation Rate Transition Satisfaction Questionnaire Self management skill | 3,9% after 3 years Disease activity: number of tender &swollen joints 0 8 (3–15) mm/hour High patient satisfaction Good self management |
DON’T RETARD | Belgium | University Hospital Leuven | JIA | 14–16 | 16 | Yes | Pediatric & adult Rheumatologist, nurse, physiotherapist, psychologist | Education, skill development, helpline (transition coordinator), Website: http://www,klueven.be/switch2/rheuma.html Peer support group | Quality of life questionnaire Disease knowledge | Improvement in physical, psychosocial, and disease-specific health status Increase in knowledge similar in control group |
Growing up and moving on | United Kingdom | 10 healthcare center | JIA | 11–17 | 16–18 | Yes | Pediatric & adult Rheumatologist, nurse, physiotherapist, occupational therapist | Education, skill development, communication forum, peer support | Quality of life questionnaire Disease knowledge Patient & patent satisfaction Pre-vocational experience | Improvement in health status Increase in disease knowledge Improvement in patients and parents satisfaction Improvement of vocational readiness marker |
Rheumatology transition programme | United State of America | Children’s Hospital of Philadelphia/ Hospital of the University of Pennysylvania | Childhood onset Rheumatic Diseases (RD) | 17–19 | Individualized, after readiness to transfer checked | Nurse specialist | Pediatric & adult Rheumatologist, nurse, social worker | Education, skill development, communication with: planner, reference book, website | Not specified | Improvement of adherence to appointments after transfer to adult rheumatology services |
YARD Clinic (Calgary) | Canada | Alberta children’s hospital Calgary foothills Hospital | Childhood onset RD | 14–25 | Individualized, after readiness to transfer checked | Nurse specialist | Pediatric & adult Rheumatologist, nurse, physiotherapist | Education, skill development, communication forum, peer support | Not specified | Improvement of adherence to appointments Good control of disease during transition Improvement in vocational readiness All patients received allied health care support |