Optimizing the Transition and Transfer of Care in Pediatric Inflammatory Bowel Disease

The gradual and intentional movement of pediatric patients toward medical self management has been endorsed as important by many professional societies. This process should start in early adolescence and can use various task lists to help establish expectations for the development of skills by the patient. Age or developmental milestones or readiness can be used as a criterion for transfer to adult care; however, anticipatory reminders will be more difficult to plan if the latter is used. Readiness can be assessed through self-report through various tools or assessed through a trained provider. These reported skills may not fully match what can be found through practical skill assessment.Questions remain regarding the best transfer criteria, optimal timing, and ideal handoff strategies. Even the outcome of successful transitioning is not well defined and thus can be hard to track. The momentum toward quality transition care grows, among individual practitioners and multicenter organizations alike. Collaborations such as the ImproveCareNow network will collect larger aggregates of data to better understand patient needs and factors that affect outcomes.59 Identifying which sets of patients require which strategies to improve self-management and have successful collaboration with adult medical providers will focus on transition care efforts. Patients with well-planned transitions seem to have improved health and outcomes for their IBD.The interest in transition care has led to a focus on patient factors beyond medical regimens. The skills, self-efficacy, problem-solving, and confidence gained by pediatric patients in the process will have profound positive consequences during the emerging adult years and perhaps beyond. Searching for how to best teach and empower patients and families will gradually become more patient-specific as understanding of the process evolves. Meanwhile, the publication of literature with observations and studies can help in a very practical way.