Measurable Outcomes for Transition: The Nurses’ Role

Abstract

This chapter highlights the importance of the role of the nurse in monitoring and tracking transition-related outcomes both pre-and post-transfer of care. Nurses play a vital role in educating adolescents and young adults (AYA) about their healthcare condition, including how to manage their condition for optimal outcomes. Additionally, nurses prepare youth for transition supporting them pre-and post-transition. Important outcomes to monitor include self-management and treatment adherence, healthcare planning, disease specific outcomes, healthcare utilization, and quality of life (QOL). Nurses, prior to transfer, have essential roles in preparing AYA for self-management of their healthcare needs. Nurses can help AYA develop the knowledge and skills needed for self-management, while monitoring and tracking treatment adherence. Additionally, nurses are ideally suited to assist AYA and their families with planning for the transition while monitoring readiness for the transfer of care. Disease specific outcomes and healthcare utilization are important to monitor both before transfer (as baseline data) and after transfer to determine the success of the transition. Finally, measuring and tracking QOL is essential. In summary, nurses can assist in tracking and monitoring outcome measures to evaluate the extent to which the healthcare transition has achieved expected outcomes.