Transition readiness and transfer from paediatric to adult health services — formative SAQs

SAQ 1 (10 marks)

A 17-year-old with type 1 diabetes has been managed solely in paediatric services. No transition plan exists and no adult provider has been identified. Outline a structured transition plan to adult care. [1] [12]

1. Define health-care transition versus simple transfer. (2) [1]
2. List the staged components of a structured transition pathway. (4) [1] [4]
3. Describe the transfer package that must travel with the young person. (4) [1]

Model answer

Transition versus transfer. Transition is the purposeful, planned, multi-year process of preparing, moving and integrating a young person from child-centred to adult-oriented care with continuous services. Transfer is only the single administrative handoff event inside that process. Treating transfer as the whole process is the central error that produces loss to follow-up. [1]

Staged pathway (Six Core Elements). Begin with a written transition policy introduced by early adolescence and normalised with the family. Track every eligible young person so none age out unseen. Assess readiness yearly with a validated tool and use the result to teach missing skills. Plan by producing a portable summary and emergency plan, searching for adult providers, and starting legal and insurance work. Transfer with a warm handoff to a named adult home, confirming the first appointment is booked. Complete with post-transfer follow-up confirming engagement. [1] [4]

Transfer package. Portable medical summary (diagnoses, problem list, history, baseline results), medication and allergy list, written emergency or safety plan (sick-day and insulin rules, hypoglycaemia plan, who to call), condition-specific care and outstanding surveillance, and key contacts with the young person's goals and preferences. The goal is that adult care inherits a complete picture and the young person keeps a safety net. [1]

SAQ 2 (10 marks)

An 18-year-old who was discharged from paediatric care with a referral letter but no confirmed adult appointment presents eight months later in diabetic ketoacidosis, having run out of insulin. [12]

1. Identify the primary systems failure and why it is unsafe. (3) [1]
2. How should the readiness questionnaire be used, and why should a low score not gate transfer? (3) [3]
3. What is the evidence for structured transition programmes, and what does it show about loss to follow-up? (4) [6] [9]

Model answer

Systems failure. This is unstructured transfer: age-based discharge with a cold referral and no secured adult home, no portable summary, and no confirmation the young person arrived in adult care. It is unsafe because the young person falls into the care gap between the family-led paediatric model and the patient-led adult model, predictably producing loss to follow-up and lapse-related acute presentations such as this one. [1] [12]

Use of readiness tools. A validated tool such as the TRAQ should be used yearly as a developmental teaching map that identifies which self-management skills to build. A low score is a reason to intensify support and adult accommodations, never a gate that withholds a transfer which will eventually happen regardless. Demanding a perfect score before any adult contact abandons the young person at the cliff. [3]

Evidence. Systematic reviews of structured transition interventions show positive effects on engagement, disease-specific knowledge, satisfaction and self-management. The unstructured default is associated with loss to follow-up and relapse. The evidence supports structured, measured pathways with warm handoffs and active outreach, particularly for the most complex and least-supported young people. [6] [9]