Development of a transition program for pediatric patients with renal disease

Background

The transition from pediatric to adult health care is challenging for patients with renal disease and inadequate transition can lead to increased disease-related morbidity. We developed a structured health care transition (HCT) program that includes a joint two-step transition clinic; the first step is the pediatric clinic and second step is the adult clinic.

Methods

Quality improvement methodology was utilized to establish an interdisciplinary transition team and conduct a needs assessment. Lack of a standardized HCT program was identified as a primary barrier to HCT. We utilized transition team and other stakeholder input to implement a transition program that included a joint pediatric/adult two-step transition clinic. Various other components were developed, including a transition policy and patient and provider feedback surveys. A pilot group of patients with kidney disease participated in the program.

Results

27 patients completed the “first step” and 22 patients completed the “second step” of the transition clinic. Median age at the time of transition was 20 years, with kidney transplant (41 %) as the major diagnosis. All patients (100 %) received the transition policy and reported that the transition team worked with them to gain skills to manage their health and plan for the future. Pediatric and adult nephrologists reported feeling satisfied (100 %) with the transition program.

Conclusion

A structured transition program was established utilizing expertise of a dedicated transition team and was well received by participants. This program is a critical first step in addressing the gap in standardized care for transition for pediatric patients with kidney disease.