Systems of care: transition from the bio-psycho-social perspective of the International Classification of Functioning, Disability and Health

Background The transition process of vulnerable adolescents, including those with complex health conditions, occurs in all domains of their life. Systems of care are usually designed but also restricted within certain aspects of life, as addressed by health, education and social welfare. The need for a co-ordinated approach to support the transition process has been voiced before, but usually publications focus on one system of care, usually the healthcare system or the education system. Recent moves, especially in the UK, are trying to integrate these different systems allowing for a more integrated transition process. This article illustrates how these developments are represented within the framework of the International Classification of Functioning, Disability and Health (ICF) and provides arguments that favour a greater integration of systems of care. Methods Examples of systems of care from North America and the EU (Germany and the UK) are described. They were selected from a literature search using the terms 'systems of care', 'transition' and 'transitional care' in different combinations. Further supportive information derives from personal experience working in some of these systems in different countries. The systems were analysed according to the components of health they address within the ICF. Results In order to assist adolescents in transition of services, there is a consensus that the approach should be individualized. The overall goal of any intervention or service should be to achieve optimal functioning of the patients. In the framework of the ICF, this means that biomedical and contextual (psychosocial) issues need to be taken into consideration. This requires an exchange of information between the different systems or the integration of those systems involved with the patient. Conclusion To facilitate transition, it has been shown that close collaboration between agencies, a transdisciplinary approach of the professionals involved and the use of key workers are helpful.