Transition (medicine)

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In medicine, transition (Latin "transitio" "transition") means the planned transition of children or young adults with chronic illnesses from child-centered to adult-oriented health care . The aim of transition medicine is to standardize and simplify this transition through various programs (in particular training courses and structured advanced training courses).

A successful transition process should be structured, comprehensive, patient-oriented and flexible so that incorrect and undersupply can be prevented. In an international comparison, Germany currently has a lot of catching up to do in terms of research projects, programs and solutions.

background

Almost 40% of children and adolescents in Germany live with a chronic health disorder , around 14% of those under the age of 18 have a special need for health care. This can be due to relatively common chronic diseases such as type 1 diabetes mellitus or diseases of the rheumatic type , but also due to disabilities , congenital malformations or rare diseases such as certain metabolic disorders. The aim of special care for these patients is not only to improve quality of life but also to avoid expensive consequential damage.

For chronically ill or disabled adolescents, the phase of transition into adulthood is associated with special tasks. They must take responsibility for the lifelong treatment of their illness or impairment and acquire the necessary knowledge and skills for this. The parents, who have generally assumed responsibility for medical and possibly also psychosocial care for many years, must, conversely, learn to pass this responsibility on to the young people. This process represents a great challenge for the entire family structure. It is particularly difficult when it comes to patients with special, very extensive or little known care needs in adult medicine. Over the years of caring for their sick children, the parents of these patients have often acquired special skills in understanding the disease and in organizing necessary medical services and psychosocial support. There is often a close, almost family relationship with the pediatric and adolescent medical team. Since real independence is not to be expected when these patients enter adulthood, the parents keep their position as responsible persons and have to find reliable contact persons in adult medicine who have sufficient understanding, time and professional expertise to provide complex care for the patients to take over and to respect the “expert role” of parents. The group of adolescents with complex illnesses and disabilities is currently most often falling out of continuous, sufficiently specialized care in the transition to adult medicine.

In addition, there is the task of finding suitable specialists to provide further support and of building a trusting therapeutic relationship with them. For some medical conditions in children and adolescents, effective treatment standards have been established and implemented, for which there are no comparable care structures in adult medicine. One reason for this is that with some complex and rare diseases, a short life expectancy has meant that until now these have been almost exclusively cared for in children and adolescent medicine. With improved therapeutic options, many of these children are now getting older and reaching adulthood without the appropriate expertise and experience in adult medicine. In addition, new knowledge about the etiology and pathogenesis of some pediatric and adolescent medical diseases have changed the therapeutic approach, in some cases considerably. In order to do justice to the treatment of these patients, adult physicians have to adapt to diseases and treatment strategies that are often strange and rare to them, which in the case of some clinical pictures entails a considerable need for further training.

Many chronically ill adolescents - around 40% - fail to make the transition to adult medicine, or only with a very delay. These young people do not find the direct route from pediatric and adolescent medical care to appropriately qualified adult medical care. Many only present there when they have suffered noticeable - often avoidable - consequential damage. This can not only have fatal health consequences for the individual, but - as already mentioned - is also of great economic, health-political and social relevance. This problem arises not so much from insufficiently developed special care in adult medicine, but is mainly related to the problems of adolescents and their families in moving to a different care structure and culture. This complex of problems results in a special need for care that goes beyond the usual medical care for the transition period. This problem and possible ways of solving it have been the subject of discussion around the world for many years.

Transition initiatives

Berlin Transition Program (BTP)

The structural problems during transition are very similar for different chronic diseases, so that a cross-indication, structural approach is useful. The Berlin Transition Program (BTP) was started in 2011 in Berlin as a model experiment for the diseases of diabetes and epilepsy and, after its completion, is to be expanded to other indications ( chronic kidney failure , juvenile rheumatoid arthritis , chronic inflammatory bowel diseases , neuromuscular diseases) and federal states.

The main part of the program are transition talks that take place before and after the transfer. Similar to U-examinations in paediatrics, the level of development of the adolescents is assessed and the need for support or necessary measures are determined. Analogous to the U-examinations, the respective status is documented in a booklet ("T-booklet"). In addition to a structured transition crisis, joint consultation hours and / or case conferences can be held. The transition process (approx. 2 years) is controlled by a central case management, which serves as a point of contact for everyone involved, supports the search for suitable options for further support, coordinates the flow of information and deadlines and ensures compliance. The transition-specific services are reimbursed within the framework of an IV contract ( integrated care ) with the health insurance companies. The DRK Kliniken Berlin , where the BTP is located, conclude contracts as a management company with the cooperating doctors and reimburse the services (transition talks, joint consultation hours, case conference, epicrisis) on a fee basis.

Finally grown up

The “finally grown up” transfer program was introduced in 2003 to make it easier for young people with chronic kidney disease to transition from the familiar environment of child dialysis to the area of ​​adult care . With the support of the Kuratorium for Dialysis and Kidney Transplantation (KfH), a training program on transfer was set up. The transfer program lasts three years and includes a seven-day seminar in the "Ederhof" rehabilitation center in East Tyrol, followed by two weekend workshops per year for the young adults. Here, insights into the treatment strategies of the adult clinic are given. Assistance in finding a career and in dealing with friends and acquaintances is another component. Sports activities support the training deficit caused by the chronic illness. At the same time, weekend seminars are also offered for parents. A computer program (OTIS) gives you the opportunity to find out about medication and to train and check your own knowledge.

"Transition" project

As part of the research program Chronic Diseases and Patient Orientation, which the Federal Ministry of Education and Research (BMBF) and statutory and private health insurance companies jointly promote, patient training on transition has been developed and tested at the Universities of Lübeck and Greifswald since 2011. In the first project phase in 2012, interviews were carried out with affected adolescents and young adults as well as experts from the fields of medicine and psychology. In this way, care needs and difficulties, needs for further training and social support could be determined. On this basis, a curriculum for patient training with youth-specific topics and various didactic methods was developed. The aim of the workshop is to empower the young people, to strengthen their self-motivation and self-competence and to increase their satisfaction with the care of their chronic illness. The program can be carried out as a weekend workshop with a group of young people aged 16 and over, the group size is at least three and a maximum of eight participants. The young people are made fit in the various areas of their health care and are well prepared for the transition to adult medicine. The focus is on the exchange between the young people and mutual support. The topics of the training include the organization of disease management, prospects for further treatment, getting to know disease-specific support offers, separation from parents, career development / training and partnership. The workshop is carried out by psychologists in cooperation with the treating paediatricians.

Project "Growing up with ModuS: Fit for change"

The project "Growing up with ModuS: Fit for change. Transition module in the modular training program for chronically ill children and adolescents ModuS" funded by the Federal Ministry of Health as part of the strategy for promoting children's health is run by the Competence Network for Patient Education in Children and Adolescents (KomPaS ) carried out. Analogous to the basic curriculum of ModuS, a cross-indication additional module for transition was developed that is suitable for a variety of health disorders and different settings (e.g. outpatient for doctor's practices, inpatient for rehabilitation clinics or large hospitals).

The transition module consists of 3 training units: 1. Growing up with a chronic illness (approx. 8 teaching units (TU) for young people). In this unit, the young people are prepared for the changes that adulthood brings with it and reflect the specifics of the disease, e.g. B. in exercising a profession, becoming self-employed and partnerships. 2. Transfer to adult medicine (approx. 4 units for adolescents). This module deals with the change of care institutions and the new doctor-patient relationship as well as the associated opportunities and risks. 3. When the children grow up (approx. 4 TU for parents). The accompanying module for parents takes up the essential content of the two youth modules. It does not replace regular parenting training, which deals with medical and psychosocial aspects of the disease and its treatment, but focuses on the young people's ability to become independent and to take responsibility for their illness. The parents are given the opportunity to exchange ideas about their new role and the difficulties and fears associated with it. The workshops take place in groups of at least 4 participants and are carried out jointly by a psychologist / educator with training experience and an expert for the respective clinical picture. A website was set up as an accompanying offer. Under the name "between - Fit for Change", it offers young people with chronic illnesses and their parents the opportunity to find out more about various topics of growing up, to exchange ideas with one another and to have experts answer individual questions.

In a controlled study, the training courses will be tested and evaluated nationwide by spring 2015, including the indications ADHD, asthma, inflammatory bowel disease, cystic fibrosis, type 1 diabetes, hemophilia and rheumatism.

Society for Transition Medicine

In order to bring together and further develop existing approaches and concepts, the "German Society for Transition Medicine eV" (DGfTM) was founded in Hanover in September 2012. Experts from several large clinics and hospital operators in Germany are involved in this. The German Society for Transition Medicine focuses on the topic of transition of chronically ill adolescents and promotes the interdisciplinary exchange of all disciplines of medicine, psychology, social medicine, genetics and sociology with the aim of establishing health policy acceptance and critically reviewing and discussing the treatment and accompanying offers . Specifically, the company plans the development of training measures under the aspect of health literacy promotion, the promotion of a cross-indication structured transition program with regulated remuneration for all transition-specific services such as transition discussions, structured epicrises, joint consultation hours, etc., the promotion of professional interdisciplinary exchange, the development of an interdisciplinary network, the initiation and support of research projects in this area, the development of guidelines, public relations and exchange and training for parents.

Transition Congress

From 9-10 November 2012 the first German congress for the transition of adolescents with chronic kidney failure and after kidney transplantation took place at the Hanover Medical School. For the future, the German Society for Transition Medicine is planning the annual alignment at changing locations and the expansion to include all clinical pictures that require an orderly transition process.

The Berlin Transition Program is organizing the 2nd Congress for Transition Medicine of the DGfTM on November 15 and 16, 2013 at the DRK Clinics Berlin. At the conference, fundamental structural, content and health-medical aspects of the transition are to be discussed with representatives from health policy, health care and payers, national and international experiences are to be exchanged and networks are to be formed. Specialists from various fields (e.g. diabetology, endocrinology, rheumatology, neurology, nephrology) from pediatric and adolescent medicine as well as adult medicine will also be represented. A project exchange is intended to enable an intensive and direct interdisciplinary exchange of experience at the various levels.

In psychiatry

Adolescents and young adults in the transition age from 15 to 25 are in a special phase of life, which brings with it a time of psychosocial upheaval and adolescence crises . It is precisely this period of life that is characterized by the frequent occurrence of mental disorders . Epidemiological studies show that eating disorders, self-harming behavior, anxiety disorders, addictions, disorders of sexual identity, delinquency or schizophrenia in transition age begin, often peak and then decrease in frequency or persist and become chronic.

It is therefore of particular interest to recognize and treat the corresponding early signs of psychological complaints in this transition age in terms of prevention. However, this necessary procedure is made more difficult in many countries by the fact that the treatment of adolescents in transition age has to be interrupted by a structural barrier. On reaching the age of majority, adolescent psychiatric patients usually experience a system change from facilities for adolescents to adult care. Structural conditions as well as scarce resources and overcrowding in child and adolescent psychiatric facilities require that patients fall under the responsibility of adult psychiatry regardless of their developmental psychological maturity. In addition to supply gaps, this break also leads to research gaps in people of transition age. For example, despite the high prevalence of self-harm and suicidality among adolescents, there are only unsatisfactory scientific results on therapeutic methods.

Transition age psychiatry is a movement that pays special attention to the individual problems of adolescence and promotes the integration of the scientific knowledge of developmental psychology and psychopathology in child and adolescent psychiatry and adult psychiatry. On December 17, 2013, experts laid the first stone of cooperation in the German-speaking area (Germany, Austria, Switzerland) at a three-country conference on the topic of "Solutions to the Problems of Transition Psychiatry". On January 22, 2016, a scientific conference of the Transition Psychiatry Working Group at the Medical University of Vienna on the subject of "Psychiatry and psychotherapy of the transition age" was successfully held in Vienna with more than 120 participants.

literature

  • Martin Reincke, Fred Zepp (ed.): Medical care in transition. Special requirements for the transition from childhood and adolescence to adulthood. (= Report Health Services Research. Volume 5). Deutscher Ärzteverlag, 2012, ISBN 978-3-7691-3495-7 .

Web links

Individual evidence

  1. ↑ C. Scheidt-Nave, U. Ellert, U. Thyen, M. Schlaud: Prevalence and characteristics of children and adolescents with special care needs in the Child and Adolescent Health Survey (KiGGS) in Germany. In: Bundesgesundheitsblatt health research and health protection. 50, 2007, pp. 750-756 doi: 10.1007 / s00103-007-0237-3
  2. ↑ Source wanted
  3. ^ Press release from the Federal Ministry of Health
  4. ↑ J. Fegert, A. Streeck-Fischer, HJ Freyberger: Adoleszenzpsychiatrie. Schattauer, Stuttgart 2009, ISBN 978-3-7945-2454-9 .
  5. ↑ ND Kapusta, JM Fegert, C. Haring, PL Plener: Psychotherapeutic interventions in suicidal adolescents. In: Psychotherapist. 2013, pp. 1–7.
  6. ↑ M. Mayr, ND Kapusta, PL Plener et al.: Transition psychiatry in adolescence and young adulthood. In: Journal of Psychiatry, Psychology and Psychotherapy. 63, 2015, pp. 155-163. doi: 10.1024 / 1661-4747 / a000235 .