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Objectives A CQC inspection highlighted the need for consistent trust-wide approach to transition and a trust audit against NICE Transition quality standards in 2017, demonstrated that patients under three or more specialities were least compliant. This led to the development of a complex healthcare transition support (CHTS) pathway which linked in the involved professionals from health, education, and social care in a Transition MDT (multidisciplinary team) meeting. Our aim was to evaluate the workload and complexity of young people (YP) referred and experience of YP and their families after care transferred. Methods Retrospective review of the CHTS database and transition multidisciplinary team (MDT) minutes for YP referred to the CHTS pathway (01/2021 – 09/2023). Patient experience feedback was obtained from YP and their families that transferred care during this period. Results 42 YP were referred to the CHTS pathway (62% female; median age at referral 16 years) and seven on the CHTS pathway fully transferred care to adult services (median age at transfer 18 years) during the study period. The 42 YP on this pathway were transitioning care across a minimum of 7 and a maximum of 24 pathways (median 14 pathways). 26 (62%) YP had a life limiting condition and six of these had an advance care plan (ACP) with a plan in progress for a further three. Seven YP had a portacath. 14 YP had a health passport and this was in progress for a further 10. 63 Transition MDT meetings (0–5 MDT meetings for each YP, median 2) occurred in this period and a further 6 were planned. These were attended by a minimum of 6 and a maximum of 27 professionals (median 12). A GP attended 9 (14%) Transition MDT's. All YP had an identified key worker, and for 86% this was the specialist nurse from the lead specialty. Patient experience feedback was received from six of the seven families that transferred care, with overall very positive feedback and a list of all the pathways and professionals from paediatric and adult services was highlighted as important to the families. Conclusion Our real-world data demonstrates very positive patient feedback and highlights the significant healthcare complexity and work involved. During this period, iterative changes occurred such as tandardizing the Transition MDT agenda, supporting primary care attendance, creation of a comprehensive document of involved professionals, linked to trust mandatory transition training with emphasis on starting preparation early and promoting ACP use. Reference Transition from Children's to adults' services. QS140. 2016.
Narula et al. (Tue,) studied this question.