Health Care Transitions最新文献

{"title":"Improving healthcare transitions for neurodevelopmental disabilities: Statewide learning collaborative outcomes","authors":"Susan Shanske MSW ,&nbsp;Abigail Ross LICSW, MPH, PhD ,&nbsp;Sarah Spence MD, PhD ,&nbsp;Ahmet Uluer DO, MPH","doi":"10.1016/j.hctj.2025.100124","DOIUrl":"10.1016/j.hctj.2025.100124","url":null,"abstract":"<div><h3>Objective</h3><div>Individuals with neurodevelopmental disabilities (NDD) encounter significant challenges during pediatric to adult healthcare transition (HCT). In response, a statewide learning collaborative was designed to improve pediatric-to-adult HCT for individuals with NDD using the Model for Improvement and the Six Core Elements of GotTransition.</div></div><div><h3>Methods</h3><div>Teams including providers from pediatric and adult practices along with family partners participated in a learning collaborative comprising two phases (Phase 1: Oct 2021–May 2022; Phase 2: Nov 2022–May 2023). Activities included monthly team meetings, learning sessions, plan-do-study-act (PDSA) cycles, and use of a transition-tracking registry. Outcomes of participation, satisfaction and usefulness of activities, resources generated, and number of patient transfers were evaluated using self-report surveys at the conclusion of each phase. Lessons learned were shared at a summit at the end of the second phase.</div></div><div><h3>Results</h3><div>Eight teams (5 primary care, 3 specialty) enrolled in the first phase while five continued in Phase 2. Throughout both phases, teams employed PDSA cycles to create provider- and family-facing resources, integrated registry components into existing systems, and engaged in monthly meetings and learning sessions. Although no team used the registry as designed, all five teams participating in Phase 2 incorporated its elements to strengthen transition workflows. Participant satisfaction was high across both phases (mean ratings &gt;4.1/5), and summit evaluations were overwhelmingly positive. Self-assessments showed modest improvements in transition practices, with persistent challenges in tracking, transfer completion, and adult integration. By phase two, 49 patients were reported as transferred or in process, with outcomes varying by team.</div></div><div><h3>Discussion</h3><div>A structured, statewide learning collaborative was feasible, highly engaging, and produced patient movement toward adult care. The results suggest that this collaborative model with facilitators embedded within teams can advance healthcare transition practices for individuals with NDD. In addition to the importance of garnering support from leadership, keystones of learning collaborative success include celebrating accomplishments, allocating dedicated resources to data collection and monitoring, embracing flexibility, and addressing resource shortcomings in the adult system of care. Future learning collaboratives designed to improve care transitions for patients with NDD would benefit from incorporating these considerations and addressing these foci explicitly.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100124"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658482","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Recruitment and retention of young adults with sickle cell disease","authors":"Tanisha Belton DrPH, MPH ,&nbsp;Lane Carbaugh BA ,&nbsp;Evelyn Stevens MPH ,&nbsp;Abigail Seide MPH, CHES ,&nbsp;Bianca Ferreira MPH ,&nbsp;Olivia Teng MSPH ,&nbsp;Laura Bennett PhD, MPH ,&nbsp;Amanda Pfeiffer LPC ,&nbsp;Mark Ferreira BA ,&nbsp;Amy Shova BS ,&nbsp;Robin Arens BS ,&nbsp;Desireé N. Williford MPH ,&nbsp;Banu Aygun MD ,&nbsp;Abena Appiah-Kubi MD, MPH ,&nbsp;Nataly Apollonsky MD ,&nbsp;Donna Boruchov MD ,&nbsp;Omar Niss MD ,&nbsp;Kim Smith-Whitley MD ,&nbsp;Sophia Jan MD, MSHP ,&nbsp;Caren M. Steinway DrPH, LMSW, MPH","doi":"10.1016/j.hctj.2026.100133","DOIUrl":"10.1016/j.hctj.2026.100133","url":null,"abstract":"<div><h3>Background</h3><div>Research has illuminated the challenges of recruiting and retaining adolescents and young adults (AYA) in research studies due to environmental, community, and personal factors. The Community Health Workers and Mobile Health for Emerging Adults Transitioning Sickle Cell Disease Care (COMETS) Study is a RCT comparing the effectiveness of two self-management support interventions, Community Health Workers (CHW) and Mobile Health (mHealth), versus enhanced usual care to improve health-related quality of life for transitioning AYA with sickle cell disease (SCD). The aim of this paper is to describe recruitment and retention strategies used in the COMETS study.</div></div><div><h3>Methods</h3><div>Recruitment and retention strategies that were identified prioritized the complex relationships between AYA with SCD and their environments. AYA (17 and older) were approached for study participation across five SCD centers in NY, PA, OH, and CT. Study team members approached patients to complete surveys at 6-, 12-, and 18- months after study enrollment.</div></div><div><h3>Results</h3><div>Of the 496 young adults approached, 405 were enrolled and 375 were randomized (median age=18 years, range=17–28). Enrolled subjects evenly identified as male (49%) and female (50%). Most participants identified as Black or African American (95%) and 8.2% of participants identified as Hispanic/Latino. Retention rates were: 82% at 6 months, 82% at 12 months and 77% at 18 months.</div></div><div><h3>Conclusions</h3><div>Implementing recruitment and retention strategies that take into consideration participant environmental, community, and personal factors are imperative for success. Study teams should be prepared for ongoing refinement of strategies based on participant and collaborator feedback.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100133"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147449193","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health literacy in adolescents with chronic disease during transition","authors":"Noriko Ozawa PhD, RN ,&nbsp;Taiga Shibayama PhD, RN ,&nbsp;Noriko Hiraga PhD, RN ,&nbsp;Kayuri Furuya DNSc, RN","doi":"10.1016/j.hctj.2026.100135","DOIUrl":"10.1016/j.hctj.2026.100135","url":null,"abstract":"<div><h3>Background</h3><div>The transition from pediatric to adult-oriented healthcare is a major challenge, and adequate health literacy is essential for achieving a smooth transition. However, knowledge is scant regarding adolescents’ health literacy during this period, and research that includes both adolescents and their parents remains limited.</div></div><div><h3>Objective</h3><div>This study clarified the health literacy of adolescents with chronic illnesses and their parents and examined differences between adolescents’ self-assessments and parents’ evaluations.</div></div><div><h3>Methods</h3><div>A cross-sectional survey was conducted with 111 adolescent–parent dyads from two hospitals in Japan. The Japanese version of the 14-item Health Literacy Scale (HLS-14) assessed functional, communicative, and critical literacy. Parents also evaluated their adolescents’ literacy. Descriptive statistics, Pearson’s correlations, paired t-tests, and intraclass correlation coefficients (ICC) were used.</div></div><div><h3>Findings</h3><div>Adolescents showed moderate literacy levels across domains (functional: M=21.18/25; communicative: M=14.6/25; critical: M=13.1/20). Functional literacy developed independently, while communicative and critical literacy were strongly correlated. Parents demonstrated lower literacy than general adult norms, particularly in communicative and critical domains. Agreement between parent ratings and adolescents’ self-reports was fair (ICC=0.35–0.42), indicating limited correspondence.</div></div><div><h3>Conclusion</h3><div>Domain-specific strategies are needed to foster adolescent health literacy. Communicative and critical literacy require intentional educational support beyond basic reading and writing. Given parents’ relatively low literacy, transition programs should incorporate parent-focused resources. Improving health literacy in both adolescents and their parents may support a smoother transition to adult-oriented care and promote independent disease management; however, further research is needed to better understand and support this process.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100135"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147656324","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The inpatient setting as an opportunity to assess healthcare transition","authors":"Luke Coffman MD ,&nbsp;Ashley McCool MHA ,&nbsp;Tanika Middleton RN, BSN, CCM ,&nbsp;Emily Nations Bufkin MD","doi":"10.1016/j.hctj.2026.100142","DOIUrl":"10.1016/j.hctj.2026.100142","url":null,"abstract":"<div><h3>Background</h3><div>Most health care transition (HCT) interventions target the outpatient setting. However, hospitalization may serve as an additional touchpoint to identify patients who require transition services.</div></div><div><h3>Local problem</h3><div>At a large urban pediatric hospital, inpatient care coordinators (CC) complete an EMR-based general assessment that includes an optional HCT screening item. Baseline data showed low item completion. The project aimed to increase the proportion of eligible admissions among patients aged ≥ 16 years with documented completion of the HCT screening item by 50% from the pre-intervention baseline within 6 months.</div></div><div><h3>Methods</h3><div>Using the Define, Measure, Analyze, Design, and Verify (DMADV) framework, monthly item completion among eligible admissions aged ≥ 16 years was tracked in a run chart. Training outcomes were assessed with anonymous before and after session surveys.</div></div><div><h3>Interventions</h3><div>Stakeholders and process owners co-developed a standardized workflow that defined an age threshold for universal inpatient HCT screening (≥16 years) and delivered an interactive CC training session on HCT concepts and CC roles in HCT.</div></div><div><h3>Results</h3><div>Documented completion increased from 44.0% in October 2024–74.4% in May 2025 (p = 0.004). In the training evaluation, after-session survey respondents reported higher self-reported confidence across survey items.</div></div><div><h3>Conclusion</h3><div>Implementing standardized inpatient workflow and CC education was associated with improved documented completion of an EMR HCT screening item among eligible admissions for patients 16 years and older. The results support the feasibility of using hospitalization as an additional touchpoint to document HCT status. Future phases will focus on implementing structural EMR changes and developing referral pathways between inpatient and outpatient CC to support patients who need additional HCT support.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100142"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148241436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Community health worker support to adolescents and young adults with sickle cell disease: A multi-method analysis on transition-related support","authors":"Jayanne Forrest BS ,&nbsp;Claudio Galea BS ,&nbsp;Caren Steinway DrPH, LMSW, MPH ,&nbsp;Olivia Teng MSPH ,&nbsp;Jack Chen MBS ,&nbsp;Sophia Jan MD, MSHP ,&nbsp;Banu Aygun MD ,&nbsp;Abena Appiah-Kubi MD, MPH ,&nbsp;Nataly Apollonsky MD ,&nbsp;Donna Boruchov MD ,&nbsp;Omar Niss MD ,&nbsp;Biree Andemariam MD ,&nbsp;Katherine Wu MPH ,&nbsp;Emmanuel Nortey MPH ,&nbsp;Kim Smith-Whitley MD ,&nbsp;Symme Trachtenberg MSW ,&nbsp;Tanisha Belton DrPH, MPH","doi":"10.1016/j.hctj.2026.100137","DOIUrl":"10.1016/j.hctj.2026.100137","url":null,"abstract":"<div><h3>Background</h3><div>Transitioning to adult care is challenging for adolescent and young adults (AYA) with sickle cell disease (SCD), often leading to increased morbidity and mortality. Community health workers (CHWs) may offer patient-centered support during this vulnerable transition.</div></div><div><h3>Methods</h3><div>We conducted a multi-method descriptive analysis of CHW encounter documentation from the CHW arm of the COMETS randomized clinical trial, which compared CHW support, mobile health, and enhanced usual care in improving health-related quality of life among transitioning AYA with SCD. Quantitative analyses characterized participant engagement and progression of participant-identified, transition-related goals during a 6-month intervention period. Qualitative analyses examined CHW documentation to contextualize how CHWs supported development of self-management and self-advocacy skills among AYA with SCD.</div></div><div><h3>Results</h3><div>Among the 120 participants (median age 18.7 years; 52% female; 92% Black or African American), 95% were successfully contacted within a median of 5 days. Participants set an average of 2.5 goals during the six-month intervention period, with 70% achieved by the end of the program. Qualitative analysis of CHW documentation revealed primary themes of transition readiness (48%), lifestyle improvements (21%), and hospitalizations or medical emergencies (19%).</div></div><div><h3>Conclusion</h3><div>This multi-method descriptive analysis demonstrates that CHWs can provide effective, scalable support for AYA with SCD during the transition to adult care. Future studies should explore the value and applicability of this model to other chronic pediatric conditions.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100137"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147995501","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Participant feedback on a health care transition conference for youth with medical complexity","authors":"Betsy Hopson PhD, MSHA,&nbsp;Jessica Brouillette,&nbsp;James Shi MPH,&nbsp;Madeline Eckenrode MD,&nbsp;Cathy Carver DPT, PT,&nbsp;Phillip Crain MPA,&nbsp;Ashley Parish PT, DPT, PhD,&nbsp;Carlie Somerville MD","doi":"10.1016/j.hctj.2026.100151","DOIUrl":"10.1016/j.hctj.2026.100151","url":null,"abstract":"<div><h3>Introduction</h3><div>Each year in the United States, an estimated 1.2 million youth with chronic conditions or functional limitations reach adulthood and must transition from pediatric to adult health care, a process often fragmented by service loss, limited adult providers, and complex waiver and financial systems. The University of Alabama at Birmingham developed the Staging Transition for Every Patient (STEP) Program which includes an annual Healthcare Transition Conference. Here we describe the conference and analyze two years of attendee feedback.</div></div><div><h3>Methods</h3><div>Conference planning followed an iterative, participatory co-design framework in which a steering committee of providers, community partners, caregivers, and individuals with lived experience shaped programming, and attendee feedback from each year informed the next. We evaluated the conference using post-conference surveys from the 2024 (n = 34) and 2025 (n = 43) events, summarized with descriptive statistics and thematic analysis; feedback from 2024 was used to tailor the 2025 program.</div></div><div><h3>Results</h3><div>Across both years, attendees valued content on medical transition, Medicaid and community waivers, financial and legal planning, and lived experience. In 2025, 88% reported being \"very likely\" to attend again. In response to 2024 feedback, the 2025 program added sessions on financial planning, guardianship, day-program sessions and an expanded self-advocate panel. Despite these changes, the 2025 cohort continued to prioritize psychosocial topics including caregiver support and respite (55.8%), social support and relationships (53.5%), and aging with a disability (51.2%).</div></div><div><h3>Discussion/conclusion</h3><div>A community-engaged, iterative conference was highly valued but revealed a persistent gap between delivered logistical content and unmet psychosocial support needs. The STEP conference offers a transferable model for community-based transition education and a method for identifying and responding to evolving family needs.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100151"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148640479","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Developing and evaluating a young adult peer mentor training program","authors":"Beth H. Garland ,&nbsp;Demonica L. Jones ,&nbsp;Cassandra J. Enzler ,&nbsp;Jean L. Raphael ,&nbsp;Albert C. Hergenroeder ,&nbsp;Rachel S. Wolfe ,&nbsp;Sarah C. Graham ,&nbsp;Constance M. Wiemann","doi":"10.1016/j.hctj.2026.100131","DOIUrl":"10.1016/j.hctj.2026.100131","url":null,"abstract":"<div><div>Improving self-management skills for adolescents and emerging adults (AEA) with chronic health conditions is critical for successful transition to adult-based care. Peer-mentoring has been effective in improving the self-management skills of AEA. However, the components of training a successful young adult peer mentors (YAPM), especially interpersonal aspects of the role, such as communication skills and navigating mentee ambivalence are not well understood. This descriptive study created and pilot-tested a training curriculum for YAPM as part of a larger study to build self-management skills in the context of healthcare transition from pediatric to adult care. Five YAPM completed the training curriculum. The curriculum included four components: 1) organizational policies and research ethics, 2) healthcare transition content and knowledge, 3) interpersonal training for the YAPM role with a focus on using Motivational Interviewing, and 4) ongoing support. Trainings included didactic, group activities, and formal simulation. YAPM rated the training components as useful, especially interpersonal training. Skill development during simulation was measured with a standardized observational coding system. Each YAPM improved in unique ways during simulation. Simulation materials are provided to allow for further development and application in future YAPM training development. This formal mentor training curriculum has the potential to clarify expectations, provide support, and help navigate the challenging interpersonal components of the YAPM role, thereby potentially increasing the effectiveness of YAPM communication with AEA to improve self-management skills.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100131"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147395816","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transition readiness in adolescents with congenital heart disease during transfer to adult care: A secondary analysis of the STEPSTONES randomized controlled trial","authors":"Hilda Malmesjö,&nbsp;Mariela Acuna Mora,&nbsp;Ewa-Lena Bratt,&nbsp;Carina Sparud-Lundin,&nbsp;Philip Moons,&nbsp;Markus Saarijärvi PhD, RN","doi":"10.1016/j.hctj.2026.100154","DOIUrl":"10.1016/j.hctj.2026.100154","url":null,"abstract":"<div><h3>Purpose</h3><div>Adolescents with congenital heart disease (CHD) are at risk of discontinuity of care during transfer from pediatric to adult services. Transition readiness is considered essential for a safe transfer. This study evaluated the effect of the STEPSTONES person-centered transition program on adolescents’ self-reported transition readiness compared with usual care.</div></div><div><h3>Design and methods</h3><div>This secondary analysis was based on a randomized controlled trial conducted at two Swedish CHD centers. A total of 139 adolescents (age 16 years) were randomized to intervention (n = 70) or usual care (n = 69). The intervention group received the STEPSTONES program in addition to usual care over two years. Transition readiness was assessed at ages 16 (T0), 17 (T1), and 18.5 (T2) using the Readiness for Transition Questionnaire. Between-group differences were analyzed with Mann–Whitney U tests, and longitudinal changes were examined using mixed-design ANOVA.</div></div><div><h3>Results</h3><div>At T2, the intervention group demonstrated significantly higher overall transition readiness compared with controls (p = .011–.015), with a small effect size (r ≈ .23–.24). A significant main effect of time was found (p &lt; .001), indicating increased readiness across adolescence in both groups. No significant group-by-time interaction was detected (p = .177), and no differences were identified at the level of individual questionnaire items.</div></div><div><h3>Conclusions</h3><div>The STEPSTONES program was associated with higher overall transition readiness at the time of transfer, although effect sizes were small. Structured, person-centered transition programs may enhance preparedness for adult care.</div></div><div><h3>Practice implications</h3><div>Pediatric nurses are key in supporting transition readiness. Structured transition programs may strengthen adolescents’ overall preparedness for adult-oriented healthcare.</div></div><div><h3>Trial registration</h3><div>ClinicalTrials.gov NCT02675361.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100154"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149199125","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The impact of a patient navigator on readiness assessment scores in youth transitioning to adult health care in Alberta","authors":"Megan Patton MSc ,&nbsp;Cassandra Chisholm MMgmt ,&nbsp;Zoya Punjwani MPH ,&nbsp;Andrew S. Mackie MD ,&nbsp;Scott Patten MD, PhD ,&nbsp;Daniella San-Martin Feeney MSc ,&nbsp;Samantha J. Anthony PhD, MSW ,&nbsp;Gina Dimitropoulos PhD, MSW ,&nbsp;Susan Samuel MD","doi":"10.1016/j.hctj.2026.100143","DOIUrl":"10.1016/j.hctj.2026.100143","url":null,"abstract":"<div><h3>Background</h3><div>At ages 16–21, youth with chronic medical conditions transition from pediatric to adult specialty care and often feel unprepared. Transition readiness assessments, including the validated Transition Readiness Assessment Questionnaire (TRAQ), may guide preparation; however, longitudinal evaluation is needed to determine their utility in supporting successful transitions.</div></div><div><h3>Objective</h3><div>(1) To compare changes in TRAQ scores between baseline, 12, and 24 months among individuals enrolled in a randomized controlled trial (RCT); and (2) to highlight insights from youth with lived expertise transitioning to adult healthcare.</div></div><div><h3>Methods</h3><div>This sub-study of the Transition Navigator Trial, a pragmatic RCT evaluating a patient navigator intervention, examined overall TRAQ scores among 129 participants. Group comparisons used the Mann–Whitney U test, and mixed models with random intercepts assessed associations between navigator access, time, and TRAQ scores. Fifteen youth partners with lived experience contributed perspectives through ongoing meetings and structured reflection on study findings; this involvement constitutes patient-oriented research and should not be interpreted as formal qualitative methodology.</div></div><div><h3>Results</h3><div>At baseline, mean TRAQ scores did not differ significantly between intervention and control groups (β=0.05, p = 0.58, 95% CI −0.12, 0.22). Regardless of treatment allocation, mean TRAQ scores increased from baseline to 12 months (β=0.54, p &lt; 0.001, 95% CI 0.44, 0.63) and from baseline to 24 months (β=0.68, p &lt; 0.001, 95% CI 0.59, 0.78).</div></div><div><h3>Conclusions</h3><div>Access to a patient navigator did not significantly influence TRAQ score trajectories; however, TRAQ scores increased significantly over time in both groups. These findings suggest that transition readiness, as measured by the TRAQ, may improve through lived experience during the transition period regardless of navigator access. Both groups received shared transition-related resources throughout the study, which may have contributed to the observed increases. Notably, the TRAQ was implemented as an indirect parallel measure in this study rather than a primary intervention target, and this should be considered when interpreting the null between-group finding. Partnering with youth enhanced interpretation of findings and underscored the importance of centering lived expertise when evaluating transition readiness outcomes.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100143"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148167845","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"No patient left behind: Developing an interdisciplinary transition clinic for young adult patients with congenital heart disease","authors":"Khadija Shah ,&nbsp;Samantha J. Klaver ,&nbsp;Sara R. Ford ,&nbsp;Suzanne McLaughlin ,&nbsp;Toi Spates ,&nbsp;Barbara Jandasek ,&nbsp;Marisa Waycuilis ,&nbsp;Janet Anderson","doi":"10.1016/j.hctj.2026.100140","DOIUrl":"10.1016/j.hctj.2026.100140","url":null,"abstract":"<div><h3>Background</h3><div>Advances in pediatric cardiology care have improved survival rates among children with congenital heart disease (CHD), resulting in a growing number of adults with CHD (ACHD). Many of these individuals encounter difficulty maintaining cardiac follow-up as they transfer into adult care. Transition clinics have emerged to support continuity of care, though best practices for their design remain unclear, and implementation varies widely across institutions.</div></div><div><h3>Objective</h3><div>This article describes the development and implementation of an interdisciplinary Cardiology Transition Clinic at an academic medical center, detailing replicable processes, highlighting challenges and successes, and reviewing implications for models of care.</div></div><div><h3>Results</h3><div>Collaboration amongst the Divisions of Adult and Pediatric Cardiology, as well as Departments of Psychology and Social Work, led to the development of a monthly Transition Clinic at the Pediatric Heart Center (PHC). Our clinical model and standardized intake forms, used to assess patients’ transition readiness, psychosocial needs, and potential transition barriers, evolved from literature review and interdisciplinary planning. Patient transition visits include assessments from an ACHD cardiologist and a pediatric psychologist. Clear communication between clinicians and medical staff has proven vital to maintaining a smooth transition and transfer process.</div></div><div><h3>Conclusions</h3><div>PHC’s Transition Clinic offers a structured, interdisciplinary approach to assessing readiness and addressing barriers to the transfer to adult cardiac care. Our model of transition services may contribute to the further development of standardized, evidence-based approaches, helping to navigate this critical stage in patient care across institutions.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100140"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147995610","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}