Table 2

Strategies for improving transition and transfer outcomes

Problem/ObstaclePaediatrics clinic strategiesAdult clinic strategies
AYA does not schedule with adult provider or misses the first adult rheumatology appointment.
  • Frame transfer as ‘graduating to adult care’; express confidence in adult provider.

  • Communicate with paediatric provider when transferred AYA misses the first appointment.

  • Transition coordinator/registry.

AYA drops out of care after the first adult rheumatology clinic visit.
  • Prepare AYA for what to expect from adult clinic and provider, highlighting:

    • Process differences.

    • Differences in clinic culture.

    • Medical practice differences.

  • Communicate with receiving adult provider before the first visit, using the TRANSFER mnemonic.

  • Use the WELCOME mnemonic:

    • Use the first visit to develop rapport with AYA and parent(s).

    • Align with paediatrics provider the WELCOME mnemonic.

    • Minimise medical changes during the first visit.

  • Communicate back to paediatric clinic after AYA’s first visit.

  • Transition coordinator/registry.

AYA lost to follow-up due to poorly timed transfer.
  • Avoid transfer during medical flare, pregnancy, other major life events.

  • Consider adult comanagement rather than full transfer of care.

AYA lost to follow-up due to scheduling policies.
  • Prepare AYA/family regarding scheduling expectations and rules of adult clinic.

  • Delineate expectations to AYA/family.

  • Encourage AYA to save office phone number in cell phone.

  • Advise AYA not to cancel without rescheduling.

AYA struggle in adult clinic due to lack of self-management skills.
  • Use readiness assessments (eg, TRAQ or Got Transition) to guide transition preparation and help determine transfer time.

  • Use readiness assessments (eg, TRAQ or Got Transition) to guide ongoing development of self-management skills.

Adolescent medicine aspects of health not explicitly addressed in the adult clinic.
  • Ask parent to leave room for all AYAs>16 years (or >12 years).

  • Encourage AYA to ask and answer questions independently.

  • Connect AYA with community resources prior to transfer.

  • Establish expectation that AYA answers questions first.

  • Perform social history with parent(s) out of the room; use HEADSS or other adolescent-focused approach to the history.

  • Assess potential barriers to care (health literacy, transportation, adherence, contraception and others).

  • Use available social work and community resources.

Poor medication adherence.
  • Consolidate medications (eg, number, dosing frequency).

  • Provide pillbox or consider prescribing blister packs.

  • Encourage free medication reminder apps like Mango Health.

  • Help patient overcome financial barriers by using a drug company patient assistance programme, applying for other medication support ( and identifying the least expensive pharmacy (,

  • AYA, adolescents and young adults; HEADSS, Home, Education/employment, Activities, Drugs, Sex/Sexuality, Suicide/depressio; TRAQ, Transition Readiness Assessment Questionnaire.