Transitional Care for Young People

Abstract

The vast majority of children born with congenital heart disease is now surviving into adulthood, thus the need to transition care from paediatric to adult facilities. The transition of care refers to the process ensuring continuity of high-quality care provided to the congenital heart disease (CHD) patient as he/she outgrows paediatric age. Clinical nurse specialist (CNS) should involve and support young adults and their families/carers in the transition process to ensure that the young person acquires knowledge and skills to be able to independently manage their health and lifelong care needs. Therfore, the close collaboration between CNS and the patient/carer should help in preventing interruption in cardiac follow-up and prepare patients for making the most a of lifelong condition. Nurses should provide a structured transition programme tailored to the individual needs and maturity, emphasising the importance of continuity of care and regular follow-up into adulthood at different transitional stage of their life. Transition nurses play a pivotal role in transition programmes, educating and empowering patients, family members and carers to ensure a smooth and successful transfer into adult services. This chapter will discuss issues related to the transition and transfer of care of young adults from the paediatric CHD setting into adult congenital heart disease (ACHD) services.