Health Care Transitions最新文献

{"title":"Self-management for youth and young adults with childhood-onset chronic conditions: A scoping review of parent and caregiver perspectives","authors":"Monique M. Ridosh PhD, RN, FAAN,&nbsp;Lin Li RN, PhD,&nbsp;Kristin Cleverley RN PhD CPMHN FAAN,&nbsp;Lexi Ewing PhD,&nbsp;Linda Tirabassi Mathis PhD RN, CPNP-PC, (CNS),,&nbsp;Cara C. Young PhD, APRN, FNP-C, FAANP, FAAN,&nbsp;Brooke Allemang PhD,&nbsp;Catherine A. Harwood MSSW,&nbsp;Lynn Kysh MLIS, MPP,&nbsp;Jennifer Emilie Mannino PhD, RN, CNE,&nbsp;Jihye Lee PhD. RN,&nbsp;Sharon Hudson PhD,,&nbsp;Manu Raam MD,&nbsp;Benjamin C. Schwartzman PhD,&nbsp;Cecily L. Betz PhD, RN, FAAN","doi":"10.1016/j.hctj.2026.100148","DOIUrl":"10.1016/j.hctj.2026.100148","url":null,"abstract":"<div><h3>Objectives</h3><div>The purpose of this scoping review was to explore self-management research conducted in the health care transition (HCT) literature, focusing on youth and young adults (YYA) with childhood-onset chronic conditions (CCC) and involving data collected from parents/caregivers regarding their perceptions and involvement in their child's self-management.</div></div><div><h3>Methods</h3><div>Articles from a larger scoping review (N = 640) that provided an overview of all articles published exploring self-management research in HCT literature were assessed for the extent to which parent/caregiver perspectives of self-management among their YYA aged 9–35 years with CCC were included in the HCT literature. The initial review criteria (protocol published in 2021) were modified to focus on primary research publications. The review process was guided by the JBI Manual for Evidence Synthesis. Study samples and methods were synthesized using descriptive analyses. Purpose statements were analyzed based on the domains of the Health Care Transition Research Consortium (HCTRC) HCT model.</div></div><div><h3>Results</h3><div>Studies (n = 218) including parent/caregiver perspectives were published from 1992 to 2025. Demographic data reported in these publications included parent/caregiver type (i.e., mother/father; 52%), age (26.6%), and race/ethnicity (21.5%). Research methods included quantitative (53%), qualitative (38.5%) and mixed (8.2%) with the majority (83%) employing a cross-sectional design. The Domains of HCTRC HCT model addressed in the literature in descending order were Individual (90%), Family/Social Support (62%) Health Care System (35%) and Environment (4%).</div></div><div><h3>Conclusions</h3><div>Research conducted with parental/caregiver input has numerous shortcomings, including inconsistent reporting of demographic data, and overreliance on cross-sectional designs. Research and practice recommendations are suggested to advance the development and implementation of inclusive models of care.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100148"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148770215","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":"Caring for children and adults with lifelong care needs across the life course","authors":"G. Currie RN, MN, PhD,&nbsp;K. Pozniak PhD,&nbsp;M. Rodrigues PhD","doi":"10.1016/j.hctj.2026.100155","DOIUrl":"10.1016/j.hctj.2026.100155","url":null,"abstract":"<div><h3>Introduction</h3><div>Children with medical complexity often have substantial care needs requiring support and care across the life course. The impact of meeting care needs across the life course affects the physical, mental health and economic status of caregiver and families. In child health, little attention is paid to the experiences and needs of caregivers as children transition to adult care. The purpose of this pan-Canadian research study is to understand the experience of parents who are primary caregivers to children and adults with medical complexity and lifelong care needs.</div></div><div><h3>Participants and Methods</h3><div>In this mixed methods study 77 caregivers completed measures of parental stress and difficult events (Pediatric Inventory for Parents, PIP), family empowerment (Family Empowerment Scale, FES), and sense of competence (Parenting Sense of Competence-Revised, PSOC-R). Twenty-one parents took part in subsequent interviews to describe their experiences, challenges and needs.</div></div><div><h3>Findings</h3><div>Mean FES subscale scores indicated moderate empowerment. Mean PSOC-R subscale scores reflected moderate parenting competence. Mean PIP–Frequency subscale scores suggested that stressful situations occurred occasionally. Mean PIP–Difficulty scores suggested stressful situations were experienced as moderately distressing and burdensome. The following themes were identified from the qualitative interviews and provide context to the quantitative surveys: a) extreme caregiving demands evolve overtime, impacting all areas of caregivers’ lives; b) health, social, and educational supports decline as children reach adulthood; c) caregivers must often find and fund their own care solutions, and d) caregivers identified a need for comprehensive wraparound supports.</div></div><div><h3>Conclusions</h3><div>While caregiving across the life course, caregivers grapple with significant challenges and lack of support to meet their child’s care needs. This study informs the need for effective holistic supports and policy solutions for caregivers and families that address needs in health, social care and education.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100155"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149199309","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":"A novel score for transition success of pediatric rheumatology patients","authors":"Kyla Blasingame ,&nbsp;David McDonald ,&nbsp;Miriah Gillispie-Taylor ,&nbsp;Tiphanie P. Vogel","doi":"10.1016/j.hctj.2026.100130","DOIUrl":"10.1016/j.hctj.2026.100130","url":null,"abstract":"<div><h3>Background</h3><div>Success of transition from pediatric to adult care depends on many factors. Various scores for transition <em>readiness</em> have been developed, but few patient-level transition <em>success</em> scores exist. Without such a metric, it is difficult to assess the impact of programmatic interventions to improve the process of healthcare transition. We created a novel transition success score for pediatric rheumatology patients.</div></div><div><h3>Methods</h3><div>Pediatric rheumatologists consulted the literature and adolescent health experts. Four components were included in the final score: attending a first adult appointment in the time frame designated by the pediatric rheumatologist (component 1), refilling medications with the adult provider within 3 months of the first adult appointment (component 2), no rheumatology-related emergency department visits in the first year after transition (component 3), and attending a second adult appointment (component 4). Scores were determined via retrospective electronic medical record (EMR) review. Each component was weighted as one-quarter of the total transition success score.</div></div><div><h3>Results</h3><div>From 2017–2024, we identified 357 patients with a final visit to pediatric rheumatology using a combination of direct provider notification of transition and EMR review. Of those, EMR records were available to score transition success for 198 patients. Optimal transition success (ie achievement of all 4 components of successful transition) was accomplished by 72/198 (36 %) patients; 77/198 (39 %) patients scored 75 %. Only 3 patients (1.5 %) scored 0 %. When considered by component, 113 patients (57 %) met component 1, 150 (76 %) met component 2, 165 (83 %) met component 3, and 159 (80 %) met component 4. We were unable to document attendance at a second adult rheumatology appointment for a surprising 20 % (39/198) of transitioned patients.</div></div><div><h3>Conclusions</h3><div>We have developed a transition success score and applied it to an initial cohort of patients who transitioned from our pediatric rheumatology clinic. Although 149/198 patients (75 %) fulfilled 3 or 4 out of 4 components of successful transition, we have identified clear opportunities for improvement. Our next steps include evaluating components of our transition program, such as patient self-reported transition readiness or receipt of a transition summary letter, against the transition success score to better understand which factors predict successful transition.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100130"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147350193","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":"Healthcare transition in spina bifida: A national mixed method study","authors":"Betsy Hopson PhD, MSHA ,&nbsp;Kathy H. Huen MD, MPH, FAAP, FACS ,&nbsp;Molly B. Richardson PhD, MPH ,&nbsp;Rhonda G. Cady PhD, RN ,&nbsp;Jennifer T. Queally PhD ,&nbsp;Judy Thibadeau RN, MN ,&nbsp;Ellen Fremion MD,FACP, FAAP","doi":"10.1016/j.hctj.2026.100128","DOIUrl":"10.1016/j.hctj.2026.100128","url":null,"abstract":"<div><h3>Introduction</h3><div>Adolescents and young adults (AYA) with spina bifida (SB) face substantial challenges during the transition from pediatric to adult healthcare, including fragmented systems, limited adult provider availability, and gaps in self-management readiness. Despite national guidelines, little is known about how transition practices are implemented across the Spina Bifida Association (SBA) Clinical Care Partner (CCP) network. This study examined clinician perspectives on current practices, barriers, facilitators, and definitions of successful healthcare transition (HCT).</div></div><div><h3>Methods</h3><div>Using an explanatory sequential mixed methods design, we first conducted a 47-item survey with clinicians from SBA CCP clinics (n = 20/32; 62.5 % response rate). Survey items assessed clinic characteristics, HCT workflows, barriers, facilitators, success indicators, and resource needs. Quantitative results informed the second phase, a 120-minute multidisciplinary focus group (n = 12) conducted at the 2025 SBA Clinical Care Meeting. The transcript underwent inductive thematic analysis, and findings from both strands were integrated using a joint display.</div></div><div><h3>Results</h3><div>Quantitative findings revealed wide variability in HCT implementation: only 15 % of sites had fully implemented workflows; 40 % tracked successful transfer. Adult provider availability, insurance instability, and transportation were the most significant barriers. Clinics strongly endorsed the need for national support, particularly in the form of an adult-provider registry (80 %). Qualitative analysis expanded these findings, highlighting critical themes of early structured HCT planning, multidisciplinary coordination, systems-level fragmentation, and the emotional burden of HCT on families and clinicians. Integrated results showed convergence around three core components of successful transition--continuity, competence, and connection.</div></div><div><h3>Discussion</h3><div>Across the SBA network, HCT processes remain early in development, constrained by limited adult workforce capacity and inconsistent infrastructure. Findings identify clear, actionable targets for the national strategy, including early planning, multidisciplinary team support, centralized SBA resources, and strengthened outcome tracking to improve continuity and long-term adult engagement.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100128"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146037959","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":"Using transition design to explore transition from adolescence to adulthood","authors":"Juliet T. Jarrell BA ,&nbsp;Olivia M. Stransky MPH ,&nbsp;Jacquelin Rankine MD PhD ,&nbsp;Loreta Matheo MD ,&nbsp;Andrew McCormick MD ,&nbsp;J.D. Tomar Pierson-Brown LLM ,&nbsp;Traci M. Kazmerski MD MS (senior authors)","doi":"10.1016/j.hctj.2026.100132","DOIUrl":"10.1016/j.hctj.2026.100132","url":null,"abstract":"<div><h3>Background</h3><div>Most existing research concerning the transition from adolescence to adulthood is narrowly focused on the healthcare setting; few studies have investigated this process holistically while including the viewpoints of young adults and their caregivers. We explored the transition from adolescence to adulthood from the perspectives of multiple constituent groups with a vested interest and expertise in this process.</div></div><div><h3>Methods</h3><div>We utilized Transition Design, a novel, qualitative methodology. We asked participants to engage in six visual mind-mapping exercises to identify problems associated with the transition to adulthood, and then solve these problems by creating a more sustainable and equitable future model. We collected data from these exercises using the virtual whiteboard platform Miro and applied thematic analysis to code for key themes.</div></div><div><h3>Results</h3><div>A total of 25 participants completed the exercises (7 young adults, 5 young adult caregivers, 4 social services providers, 9 healthcare providers). Overall, all participants focused on mental health and increasing access to resources. However, each constituent group prioritized a different aspect and level of society in their responses; young adults emphasized large-scale societal themes and structural changes, social services providers emphasized improving access to community resources, caregivers emphasized the role of advocacy, and healthcare providers emphasized the health sector.</div></div><div><h3>Discussion</h3><div>Results highlight the complexity of transition across broad societal domains and the unique perspectives of constituent groups. These results can help to inform future research in this area while improving transition from adolescence to adulthood, both within and outside of the healthcare setting.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100132"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147395691","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":"Design and rationale for Exploring Predictors of successful healthCare Transition for adolescents with chronic conditions in a longitudinal explorative cohort","authors":"M.S. Vletter ,&nbsp;J.W. Hoefnagels ,&nbsp;A.L. van Staa ,&nbsp;S.L. Nijhof ,&nbsp;J.W. Gorter ,&nbsp;J.N.T. Sattoe","doi":"10.1016/j.hctj.2026.100129","DOIUrl":"10.1016/j.hctj.2026.100129","url":null,"abstract":"<div><h3>Background</h3><div>Transitioning from paediatric to adult healthcare is a pivotal phase for adolescents and young adults (AYAs) with chronic conditions. Effective healthcare transition (HCT) supports continued healthcare engagement and stable psychosocial outcomes, reducing risks for patients, their families, and the healthcare system. Yet the determinants of a smooth transition are complex, shaped by the interplay of various biopsychosocial constructs.</div></div><div><h3>Objective</h3><div>The ExPeCT study (acronym: Exploring Predictors of a successful healthCare Transition) seeks to: A) examine the relationship between biopsychosocial development, transition readiness, and HCT outcomes, including patients’ experiences; and B) identify key predictors of successful HCT in AYAs with chronic conditions.</div></div><div><h3>Method</h3><div>This longitudinal, observational, exploratory cohort study is embedded in the PROactive cohort, which annually measures biopsychosocial well-being of children with chronic conditions. The ExPeCT study supplements the PROactive cohort by collecting additional data on HCT experiences at three time points: once in paediatric care and twice after transfer to adult care.</div><div>Data will be obtained from a range of chronic disease groups. Advanced statistical modelling will be employed to analyse transition outcomes and experiences, and to investigate associations between biopsychosocial development and transition readiness.</div></div><div><h3>Significance</h3><div>This study is expected to fill a critical gap in the field by providing comprehensive understanding of predictors of successful healthcare transition in AYAs with chronic conditions. The insights gained will help improve care strategies and guide healthcare professionals in supporting successful transition to adult care.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100129"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147358363","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":"Adulthood as a social construct: Critical discourse analysis of transition preparation consultations for youth with chronic conditions","authors":"Maxime Morsa,&nbsp;Clémentine Boudroit,&nbsp;Agnes Dumas,&nbsp;Enora Le Roux,&nbsp;Paul Jacquin,&nbsp;Hélène Mellerio","doi":"10.1016/j.hctj.2026.100145","DOIUrl":"10.1016/j.hctj.2026.100145","url":null,"abstract":"<div><h3>Background</h3><div>Little is known about how interventions designed to empower youth with chronic conditions operate in natural clinical contexts during the transition from pediatric to adult care. Such interventions may contribute to social learning through discourse about the future, illness, and adolescence, thereby shaping youths’ understandings of identity and empowerment. This study examined how meanings of transition are discursively constructed during Transition Preparation Consultations (TPCs), a structured intervention delivered within the AD’venir transition unit in France for youth with diverse chronic conditions.</div></div><div><h3>Methods</h3><div>We conducted a critical discourse analysis of 26 TPCs, focusing on the discursive resources and positioning practices through which youth and physicians constructed meanings of transition.</div></div><div><h3>Results</h3><div>TPCs framed transition as a psychological and social process, encouraging youth to develop experiential understandings of illness and identity. Consultations primarily focused on self-management, living with a chronic condition in adulthood, and health maintenance, while discussions were frequently anchored in bodily changes associated with adolescence. Although physicians often adopted pedagogical and dialogic forms of communication, interactions remained largely structured by prescriptive discourses regarding responsibility, self-management, and adult health behaviors.</div></div><div><h3>Conclusions</h3><div>Transition programs function not only as organizational interventions but also as discursive spaces in which meanings of illness, responsibility, autonomy, and adulthood are actively produced. Recognizing these processes may support critical reflection and the ongoing refinement of transition practices.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100145"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13292538/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148335406","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":"Evaluating transitional care practices for adolescents with chronic conditions in two Dutch university hospitals: A mixed-methods study","authors":"Jobert Sturm,&nbsp;Myrthe Braunstahl,&nbsp;Heidi van Heijningen-Tousain,&nbsp;Marieke van Summeren,&nbsp;Jane Sattoe,&nbsp;Johanna C. Escher,&nbsp;AnneLoes van Staa","doi":"10.1016/j.hctj.2026.100149","DOIUrl":"10.1016/j.hctj.2026.100149","url":null,"abstract":"<div><h3>Background</h3><div>The transition from paediatric to adult healthcare represents a critical period for young people with chronic conditions. Although structured transitional care is recommended both nationally and internationally, its implementation remains inconsistent across healthcare settings. This study aimed to examine the implementation of transition interventions in two Dutch university hospitals and to identify determinants shaping their implementation in routine practice.</div></div><div><h3>Methods</h3><div>This convergent mixed-methods study evaluated 50 medical specialties across paediatric and/or adult services. Ninety healthcare professionals participated. Data were collected through semi-structured interviews and a structured verbal questionnaire assessing the presence of key transition interventions across preparation, transfer, and post-transfer integration phases. Interview data were analysed thematically, questionnaire data descriptively, and integrated findings were used to assess adherence to principles of transitional care.</div></div><div><h3>Results</h3><div>Implementation varied across specialties and phases of care. A transition coordinator was reported in 31% of medical specialties. Individual transition plans were reported in 31% of paediatric services and 18% of adult services. A warm handover was reported in 53% of specialties. Key facilitators included defined roles, cross-boundary collaboration, and organisational support. Barriers comprised limited resources, insufficient adult-care involvement, and a lack of routinised processes. Principle-based scoring indicated mid-range implementation across specialties in both hospitals (range 8–27 on an 8–32 scale; median 14.5, IQR 12–20).</div></div><div><h3>Conclusions</h3><div>Transitional care was implemented inconsistently across medical specialties in both hospitals, with the largest gaps occurring after transfer to adult care. Stronger organisational support, explicit coordination, routinised paediatric–adult care collaboration, and shared accountability may improve consistency and developmental appropriateness.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100149"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148640465","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":"TRAQ in clinical practice: A narrative review for health care transition readiness","authors":"Betsy Hopson PhD, MSHA,&nbsp;Kylee R. Phalen,&nbsp;David Wood MD, MPH","doi":"10.1016/j.hctj.2026.100152","DOIUrl":"10.1016/j.hctj.2026.100152","url":null,"abstract":"<div><h3>Background</h3><div>Advances in medical care have dramatically improved survival rates for children and youth with special health care needs (SHCN), with more than 90% now reaching adulthood. As a result, pediatric-to-adult health care transition has become a critical component of lifespan care. Despite national consensus recommendations, fewer than one in four adolescents receive the transition services needed to prepare them for adult-oriented care. Standardized, validated instruments to assess and promote transition readiness are essential to close this gap.</div></div><div><h3>Objective</h3><div>This review describes the practical application of the Transition Readiness Assessment Questionnaire (TRAQ) in ambulatory care settings, to guide clinicians in its administration, interpretation, and integration with evidence-based counseling strategies.</div></div><div><h3>Methods</h3><div>This narrative review synthesizes published literature and the authors' collective clinical experience implementing the TRAQ across ambulatory transition programs. Sources include the three successive TRAQ validation studies, national consensus guidelines, and behavior change literature underpinning the instrument's theoretical framework. The Transtheoretical Model of Behavior Change and Motivational Interviewing are presented alongside a structured clinical framework for iterative assessment, goal-setting, and follow-up.</div></div><div><h3>Results</h3><div>The TRAQ is a validated, theory-driven instrument spanning four behavioral domains of health and health care self-management. It supports providers in systematically evaluating readiness, identifying skill gaps, and facilitating self-management development across adolescence. Practical guidance is provided for score interpretation, stage-matched counseling approaches, and a TRAQ Companion Individualized Transition Plan (ITP) for structured goal documentation and follow-up.</div></div><div><h3>Conclusions</h3><div>Systematic use of the TRAQ within a structured transition counseling framework enables clinicians to evaluate readiness and tailor interventions to each youth's stage of change. Integration of the TRAQ and its companion ITP into routine ambulatory practice represents an evidence-informed approach to improving health care transition outcomes for adolescents and young adults (AYAs) with SHCN.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100152"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149003675","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":"Transition backslide: Patterns of patient reengagement with a pediatric health system after a coordinated transfer to adult care","authors":"Adam Greenberg MSN, RN ,&nbsp;Lorene Schweig MS ,&nbsp;Walter Faig PhD ,&nbsp;Dava Szalda MD, MSHP ,&nbsp;Ruth Lebet PhD ,&nbsp;Elizabeth B. Froh PhD, RN","doi":"10.1016/j.hctj.2025.100127","DOIUrl":"10.1016/j.hctj.2025.100127","url":null,"abstract":"<div><h3>Background</h3><div>Transition to adult healthcare systems is a complex process for young adults with chronic diseases and/or developmental disabilities. Our pediatric health system (PHS) created a referral-based multidisciplinary transition team (MTT) to support complex transfers, yet some patients continued to reengage post-transfer of care. We aimed to identify these patients, characterize patient-initiated reengagement trends, and assess factors associated with reengagement.</div></div><div><h3>Methods</h3><div>We conducted a retrospective observational study of patients referred to the MTT between July 1, 2017, and June 30, 2019, who had transitioned from pediatric to adult care providers by June 30, 2020. Data were extracted from the MTT clinical database and electronic health records.</div></div><div><h3>Results</h3><div>Of 73 eligible participants, 63 (86 %) reengaged with the PHS at large after transfer of care, accounting for 540 separate encounters. Reengagement encounters were categorized as anticipated (56 %, n = 302), unanticipated (33 %, n = 181), or specifically with the MTT (11 %, n = 57). Average time to first reengagement encounter differed significantly across groups (<em>p</em> &lt; 0.0001): 28 days (MTT), 53 days (anticipated), and 99 days (unanticipated). No clinical or utilization variables were associated with time to first reengagement in unanticipated encounters or with the MTT. In anticipated encounters, reengagement was associated with prior cardiology care (HR=2.353, <em>p</em> = 0.0494), number of pediatric subspecialty providers (HR=1.01, <em>p</em> = 0.0309), and number of prescribed medications at transition (HR=1.05, <em>p</em> = 0.0477).</div></div><div><h3>Conclusion</h3><div>Reengagement with PHS post-transfer of care was common, even among patients transitioning with structured support from our MTT. These findings underscore the need for continued PHS support even after transferring to adult healthcare systems.</div></div>","PeriodicalId":100602,"journal":{"name":"Health Care Transitions","volume":"4 ","pages":"Article 100127"},"PeriodicalIF":0.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145938876","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}