Health Care Transition Readiness Research Articles

STARx Health Care Transition Readiness Scores among Arabic-Speaking Youth with Chronic Conditions

STARx Health Care Transition Readiness Scores among Arabic-Speaking Youth with Chronic Conditions

Responses from Arabic-Speaking Caregivers of Youth with Chronic Conditions to the Health Care Transition Readiness Starx Questionnaire

Responses from Arabic-Speaking Caregivers of Youth with Chronic Conditions to the Health Care Transition Readiness Starx Questionnaire

Assessing health care transition readiness in adolescents with asthma through a portal-based initiative

Assessing health care transition readiness in adolescents with asthma through a portal-based initiative

Human-centered design approach to building a transition readiness mHealth intervention for early adolescents.

Mobile health (mHealth) interventions may be an efficacious strategy for promoting health behaviors among pediatric populations, but their success at the implementation stage has proven challenging. The purpose of this article is to provide a blueprint for using human-centered design (HCD) methods to maximize the potential for implementation, by sharing the example of a youth-, family-, and clinician-engaged process of creating an mHealth intervention aimed at promoting healthcare transition readiness. Following HCD methods in partnership with three advisory councils, we conducted semistructured interviews with 13- to 15-year-old patients and their caregivers in two phases. In Phase 1, participants described challenges during the transition journey, and generated ideas regarding the format, content, and other qualities of the mHealth tool. For Phase 2, early adolescents and caregivers provided iterative feedback on two sequential intervention prototypes. Data were analyzed using thematic analysis in Phase 1 and the rapid assessment process for Phase 2. We interviewed 11 youth and 8 caregivers. The sample included adolescents with a range of chronic health conditions. In Phase 1, participants supported the idea of developing an autonomy-building tool, delivering transition readiness education via social media style videos. In Phase 2, participants responded positively to the successive prototypes and provided suggestions to make information accessible, relatable, and engaging. The procedures shared in this article could inform other researchers' plans to apply HCD in collaboration with implementation partners to develop mHealth interventions. Our future directions include iteratively developing more videos to promote transition readiness and implementing the intervention in clinical care.

The pervasive influence of systems of power on transition readiness for adult care in sickle cell disease: A qualitative study.

Adolescence and young adulthood are vulnerable developmental periods for individuals with sickle cell disease (SCD), particularly given the impact of social inequities, challenges with transitioning to adult healthcare services, and increased risk for morbidity and mortality. Systems of power, such as institutionalized and interpersonal manifestations of bias, could impact SCD transfer and engagement in adult care through their influence on healthcare transition readiness; yet research in this area is limited. To characterize how systems of power impact transition readiness factors described in the Social-ecological Model of AYA Readiness for Transition to Promote Health Equity (SMART-E) framework at the patient, caregiver, and practitioner levels. Pediatric adolescents and young adults (AYA), transferred AYA, caregivers, and practitioners participated in semi-structured focus groups and individual interviews examining health equity and systems of power during healthcare transition. Focus groups/interviews were transcribed and coded using a deductive approach via the updated SMART-E framework. Ten pediatric AYA with SCD, nine transferred AYA with SCD, eight caregivers, and nine practitioners participated in a focus group or interview. Qualitative findings across reporters emphasize the impact of systems of power (e.g., racial bias and disease stigma) on knowledge, skills and self-efficacy, beliefs and expectations, goals and motivation, and emotions and psychosocial functioning at the patient, caregiver, and practitioner levels. Systems of power are prevalent with respect to transition barriers for AYA with SCD and their supports. Structural, institutional, and individual factors with potential to reduce the influence of systems of power should be further identified and targeted for intervention.

Factors associated with healthcare transition readiness for adolescents with chronic conditions: A cross-sectional study.

Healthcare transition readiness (HCTR) plays a vital role by fostering autonomy, self-management skills, and active involvement in healthcare, leading to positive health outcomes. This study aimed to examine the factors associated with HCTR in adolescents with chronic conditions (ACCs) including adolescents' autonomy, parental overprotection, and autonomy support from healthcare providers (HCPs). This descriptive study included 107 adolescents aged 14-19years (median age: 17years, IQR = 1), recruited from online communities and support groups in South Korea. Data were analyzed using hierarchical linear regression. Our research has shown that HCTR is linked to a lower level of parental overprotection (β = -0.46, 95% CI [-0.59, -0.33]) and higher levels of autonomy support from HCPs (β = 0.46, 95% CI [0.36, 0.56]). Among general characteristics, we also found that having a transfer plan to adult care (β = 0.24, 95% CI [0.04, 0.44]) is significantly associated with HCTR. This study contributes to a broader understanding of HCTR by examining its associated factors in ACC. The results emphasize the pivotal roles of parental involvement, healthcare provider support, and structured transition to adult care in enhancing HCTR. These findings underscore the need for comprehensive assistance to ensure successful healthcare transitions.

Transitioning from Pediatric- to Adult-focused Dialysis Care: A Systematic Review with Recommendations

Background: There is limited data evaluating the practices of nephrologists who prepare dialysis-dependent adolescents and young adults (AYA) for healthcare transition (HCT) from pediatric- to adult-focused healthcare. The aims of this manuscript are to 1) critically evaluate the current evidence and experiences surrounding HCT from pediatric- to adult-focused dialysis units and 2) make recommendations that can be implemented for this process. Methods: We searched PubMed, EMBASE, CINAHL, COCHRANE, and clinicaltrials.gov to identify studies that pertain to the HCT of AYA patients from pediatric- to adult-focused dialysis care. Results: A total of 14 studies were included and were grouped into subcategories to facilitate data synthesis: HCT process, preparedness of patient and family, preparedness of adult-focused nephrology providers, barriers to HCT, and quality of life. These included studies highlight the importance of creating an HCT process with a formal policy. They focus on the importance of patient and family preparedness and on measuring HCT readiness using standardized scales. They also underline the importance of identifying adult-focused nephrology ‘HCT champions’ to care for AYA requiring dialysis. Lastly, they emphasize the importance of measuring the quality of life in AYA patients to ensure optimal patient-centered HCT. Conclusion: There is limited data on HCT for AYA with ESKD. Upon review and analysis of current literature, we recommend: creating a formal, written HCT policy; setting achievable goals for health self-management and conducting regular assessments of HCT readiness; identifying a lead or ‘champion’ at an accepting adult-focused dialysis unit and ensuring good communication between pediatric and adult providers; and completing annual quality-of-life assessments.

Healthcare transition readiness of families of youth with cystic fibrosis during COVID-19: A correlational multicenter analysis

BackgroundEnhancing family readiness for the healthcare transition (HCT) to adult-focused care can help adolescents and young adults (AYA) thrive in adulthood. We aimed to explore modifiable and non-modifiable individual, family, and healthcare factors associated with HCT readiness of AYA among families of AYA with cystic fibrosis (CF) during COVID-19. MethodsA multi-site, cross-sectional design was used and an online survey was deployed among families and their AYA from three US pediatric CF centers. The STARx Transition Readiness Questionnaire assessed caregiver- and AYA-perceived HCT readiness of AYA. ResultsCaregivers (N = 71) and their AYA with CF (N = 33, aged 12–21 years) perceived moderately high HCT readiness of AYA. Caregiver resilience was a significant (p = 0.006), family-level factor correlated with caregiver-perceived HCT readiness. ConclusionsFamilies perceived similar levels of AYA readiness for adult-focused care. Caregiver resilience is an important, modifiable family-level factor for targeted interdisciplinary interventions aimed at enhancing HCT processes during COVID-19.

Barriers to a successful healthcare transition for individuals with urea cycle disorders.

The pediatric to adult healthcare transition (HCT) is a process for individuals with chronic health conditions to gradually shift from a pediatric to an adult-oriented care system. Autonomy and self-management skills required for an individual's HCT readiness can be evaluated through the transition readiness assessment questionnaire (TRAQ). Despite general HCT preparation guidelines, little is known about the HCT experience of individuals with a urea cycle disorder (UCD). This is the first study to report the parent or guardian perception of the HCT process in children with a UCD by investigating the stages of transition readiness and transition outcome. We identify barriers to HCT readiness and planning, along with deficiencies in transition outcome for individuals with a UCD. For children that received special education services compared to those that did not, significantly lower transition readiness scores were identified in the total TRAQ score (p=0.03) and in the domains of tracking health issues (p=0.02), talking with providers (p=0.03), and managing daily activities (p=0.01). There was a lack of HCT preparation as most subjects did not have a HCT discussion with their healthcare provider before age 26. Deficiencies in HCT outcome are demonstrated by individuals with a UCD reporting delays in needed medical care and dissatisfaction with their healthcare services. Considerations for facilitating a successful HCT for individuals with a UCD include providing individualized education, appointing a transition coordinator, allowing flexibility in HCT timing, and ensuring that the individual recognizes concerning UCD symptoms and knows when to seek medical care.

1041-P: Health Care Transition Practices in the T1D Exchange Quality Improvement Collaborative

Background: Implementation of a structured health care transition (HCT) process is associated with positive outcomes in population health, experience of care, and health care utilization. Objective: To describe pediatric and adult clinic HCT practices in the T1D Exchange Quality Improvement Collaborative (T1DX-QI). Methods: Got Transition’s Six Core Elements of HCT offer a structured approach to the phases of transition support: 1) transition and care policy, 2) tracking and monitoring, 3) transition readiness, 4) transition planning, 5) transfer of care, and 6) transfer completion. T1DX-QI institutions (n=53) were surveyed to examine the integration of the Six Core Elements into diabetes HCT practices. Results: The survey response rate was 94.3% (n=50 clinics; 33 pediatric, 17 adult). A majority of T1DX-QI pediatric clinics (72.7%, n=24) report having a HCT policy compared to 29.4% (n=5) of adult clinics. Among pediatric institutions, 45.4% (n=15) maintain a tracking system to identify transition-aged youth, 39.4% (n=13) formally assess HCT readiness, 52% (n=17) document and update a plan of care for transition and 27.3% (n=9) have a process in place to confirm successful transfer of care completion with adult diabetes providers. Approximately two-thirds of T1DX-QI pediatric institutions (63.6%, n=21) have a formal structured HCT program and 29% (n=6) of these HCT programs report incorporating all 6 elements. Conclusions: Data from T1DX-QI centers highlight opportunities to further enhance transition preparation and receivership for emerging adults with type 1 diabetes. The Six Core Elements offer a potential avenue to structure improvement initiatives since many diabetes clinics only partially incorporate these elements in current practice. Partnerships between pediatric and adult diabetes centers should be considered as part of quality improvement efforts to facilitate incorporation of challenging HCT elements such as transfer of care completion. Disclosure F.Malik: None. G.T.Alonso: None. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. S.Corathers: None. T1dx-qi collaborative: n/a. J.Cases-villablanca: None. M.E.Hilliard: None. S.Lyons: None. L.M.Jacobsen: None. A.J.Roberts: None. A.Mucci: None. S.Agarwal: Advisory Panel; Medtronic, Consultant; Beta Bionics, Inc., Research Support; Abbott Diabetes, Dexcom, Inc. C.Demeterco-berggren: Speaker's Bureau; Glooko, Inc. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Depressive Symptoms, Cannabis Use, and Transition Readiness among College Students with and without Chronic Medical Conditions

Background: College students experience increased responsibility for healthcare transition. They are at increased risk for depressive symptoms and cannabis use (CU), potentially modifiable predictors of successful healthcare transition. This study investigated how depressive symptoms and CU related to transition readiness, and if CU moderated the association between depressive symptoms and transition readiness for college students. Methods: College students (N = 1,826, Mage=19.31, SD = 1.22) completed online measures of depressive symptoms, healthcare transition readiness, and past-year CU. Regression identified 1) the main effects of depressive symptoms and CU on transition readiness and 2) examined if CU moderated the relationship between depressive symptoms and transition readiness with chronic medical conditions (CMC) status as a covariate. Results: Higher depressive symptoms were correlated with past-year CU (r=.17, p<.001) and lower transition readiness (r=-0.16, p<.001). In the regression model, higher depressive symptoms were related to lower transition readiness (ß=-0.02, p<.001); CU was not related to transition readiness (ß=-0.10, p=.12). CU moderated the relationship between depressive symptoms and transition readiness (B=.01, p=.001). The negative relationship between depressive symptoms and transition readiness was stronger for those with no past-year CU (B=-0.02, p<.001) relative to those with a past-year CU (ß=-0.01, p<.001). Finally, having a CMC was related to CU and higher depressive symptoms and transition readiness. Conclusions: Findings highlighted that depressive symptoms may hinder transition readiness, supporting the need for screening and interventions among college students. The finding that the negative association between depressive symptoms and transition readiness was more pronounced among those with past-year CU was counterintuitive. Hypotheses and future directions are provided.

Transition readiness in adolescents and young adults with chronic genetic skin conditions.

Healthcare transition (HCT) refers to movement from pediatric to adult healthcare models. Lack of HCT preparation contributes to poor health outcomes. This study measures readiness to transition in individuals with genetic skin conditions. Participants signed IRB-approved consents/assents. Participants ages 14-22 years with genetic skin disorders were surveyed with measures of QoL (Children's Dermatology Life Quality Index/CDLQI or DLQI) and HCT readiness using the Transition Readiness Assessment Questionnaire (TRAQ) and adapted non-validated measures of Skin Knowledge and Psychosocial Factors (5 = highest readiness). Mean TRAQ was compared with historical data on controls and other chronic conditions (t-tests) and correlated (Pearson) with Skin Knowledge and Psychosocial. Multivariable regression compared demographics and QoL with transition readiness. A total of 45 participants were enrolled (mean age 17.8 years, 67% female, 71% White; disorders of cornification [n = 31], ectodermal dysplasias [n = 7], epidermolysis bullosa [n = 4], tuberous sclerosis [n = 3]). Mean TRAQ (3.3 ± 0.9) was lower than controls (3.9; p < .001) and some chronic disorders (sickle cell [3.7; p < .05], type 1 diabetes [3.7; p < .01]), but higher than with spina bifida (2.8; p < .001) and congenital heart disease (2.9; p < .01). Mean Skin Knowledge was 4.2 ± 1.0, and mean Psychosocial was 3.4 ± 0.8. TRAQ correlated strongly with Skin Knowledge (r = .61; p < .05), but not Psychosocial (r = .12; p = .6). Ages 14-17 years versus 18-22 years and public versus private insurance predicted lower TRAQ scores. Poor DLQI predicted higher TRAQ and Skin Knowledge, but poor DLQI and CDLQI predicted lower Psychosocial. Adolescents and young adults with genetic skin disorders demonstrated low transition readiness, especially among younger-aged and lower socioeconomic groups. We recommend a HCT intervention to improve health outcomes.

Perceptions of caregivers and adolescents/young adults with cystic fibrosis regarding health care transition readiness during the COVID-19 pandemic: A qualitative study

PurposeMedical advances have increased the life expectancy of adolescents and young adults (AYA) with cystic fibrosis (CF) and importance of high-quality health care transitions (HCT) from pediatric-to-adult focused health care. The purpose of this study was to describe perceptions of HCT readiness among caregivers and AYA with CF during the COVID-19 pandemic. Design and methodsUsing a qualitative descriptive design, caregivers and AYA aged 12–21 years old were recruited from three large CF care centers across the eastern U.S. Data were collected using an online questionnaire with open ended and closed ended questions. Survey topics were: perceptions of HCT readiness, actions to prepare for HCT, and the impact of COVID-19. Results were interpreted using an adapted framework of the Health Care Transition Research Consortium Model and qualitative content analysis. ResultsThe sample included 73 caregivers (62 mothers) and 34 AYA (24 female, mean age 15.5 years). Three attributes of HCT readiness were identified from caregiver and AYA perceptions: (1) strong concerns that AYA lacked readiness to manage self-care needs in the future, (2) gaps in resources hindered ongoing efforts to enhance transition readiness, and (3) COVID changes created new barriers and facilitators to health care transition readiness. ConclusionsCaregivers and AYA felt they lacked readiness for HCT, they worried about worsening outcomes in adult-focused care, and they were challenged by the onset of the COVID-19 pandemic. Practical implicationsThese findings provide a solid description of perceived transition readiness during a pandemic that may enhance transitional care design.

Sickle cell disease and adolescents’ perspectives on self-care management resources

BackgroundAdolescents with sickle cell disease (SCD) face unique challenges, especially during the critical health care transition from pediatric to adult care. The purpose of this study was to gather the perspectives of adolescents living with SCD and to describe their self-care management experiences prior to their move into the adult health care system. MethodsGuided by the Theory of Self-Care Management for Sickle Cell Disease, this qualitative descriptive study used semi-structured interviews with 11 adolescents with SCD (M = 16.63 years, SD = 1.15). In addition to a demographic survey, adolescents answered interview questions about their perceptions of their self-care management, health care transition readiness, support, and spiritual well-being. Data were analyzed using a template analysis style. ResultsFour major themes were identified: attaining vocational aspirations, maintaining effective self-care management strategies, managing and maintaining social support, and building resilience through spirituality and religion. Maintaining, effective self-care management strategies had three threads: coping behaviors, health care transition needs, and self-care management strengths. DiscussionIdentifying self-care management resources and areas where further attention is needed can be helpful for health care providers when developing age specific plans. A tailored approach to care during this critical health care transition period can also build capacity for a successful transition for adolescents.

Translation and validation of the STARx questionnaire in transitioning Chinese adolescents and young adults with chronic health conditions

BackgroundAdolescent/young adults (AYAs) with chronic conditions must undergo healthcare transition (HCT) preparation until their mid-twenties. Valid HCT readiness measures are lacking in China. MethodsThe present study translated, back-translated, and adapted the Self-Management and Transition to Adulthood with Rx = Treatment (STARx) Questionnaire. We examined the psychometric properties of this tool in a relatively large in-patient sample of AYAs with various chronic health conditions at a Chinese tertiary general hospital. ResultsWe enrolled 624 AYAs aged 10–25 years (19.66 ± 3.64) with various chronic health conditions. The Chinese version of the STARx Questionnaire demonstrated excellent internal consistency (Cronbach's alpha = 0.83) and reliability with a two-week test-retest (ICC = 0.88, p < .001). Furthermore, the Chinese version revealed a three-factor structure (self-management, disease knowledge, and provider communication) consistent with the revised English version of the STARx Questionnaire. In terms of discriminant validity, the total score of the Chinese STARx Questionnaire showed a significant positive correlation with age but no gender differences were found. In terms of predictive validity, the Chinese STARx Questionnaire was significantly correlated with shorter length of hospitalization and higher frequency of emergency room visit, but the correlations became insignificant after controlling for age. ConclusionsThe results suggest that the Chinese version of the STARx Questionnaire is a robust HCT readiness tool in AYAs with chronic conditions and clinicians may find it useful to develop individualized interventions.

Parental Perspectives on Health Care Transition in Adolescent and Young Adult Survivors of Pediatric Cancer.

The health care transition (HCT) from pediatric to adult care is pivotal for childhood cancer survivors (CCS) and their parents. However, there is little research examining parental needs during HCT, despite this being a key predictor of successful HCT. The goal of this study was to investigate the needs of parents of CCS during HCT. Using an integrative review of the literature structured around the social-ecological model (SEM) of CCS transition readiness yielded 454 articles, including three hand-searched articles. Six articles were included in the final analysis. Data were extracted into nine factors derived from SEM. Articles were published within the last decade, largely qualitative, and mainly examined parents and CCS together. Parents most frequently mentioned relationships with their practitioner and CCS as contributing to HCT readiness, while abstract factors, such as goal-setting and expectations around HCT, were not mentioned. Our results are limited by the dearth of research on this topic, the homogeneity of samples, and joint presentation of CCS and parent data. Nonetheless, our results indicate that parents do not weigh all aspects of SEM equally, with macrolevel barriers, such as sociodemographic factors being viewed as less salient for HCT readiness. Parents mostly focused on interpersonal factors, such as their relationships with practitioners and CCS, indicating that practitioners should emphasize these in preparing parents for HCT.

The self-management and transition manual “ALL YOU NEED IS LOVE” for adolescents with chronic kidney disease

PurposeTo examine the effects of “ALL YOU NEED IS LOVE”, a novel six-week, self-directed patient education manual designed to improve chronic kidney disease knowledge/self-management, health care transition readiness, self-advocacy, and mindfulness skills among adolescents with chronic kidney disease. Design and methodsWe enrolled 49 adolescents aged 11–17 years (mean age 14.7 ± 1.9; 53.1% males) from a university hospital kidney center who had CKD stages 3 and greater, who were randomly assigned into the “ALL YOU NEED IS LOVE” patient education only group (n = 31) or the “ALL YOU NEED IS LOVE” patient education plus mindfulness training group (n = 18). Participants completed Qualtrics surveys at baseline, post-intervention, and three-month follow-up. The survey included measures of outcome variables (i.e., self-management/transition readiness, patient self-advocacy, and mindfulness), and an additional demographic questionnaire was included in the baseline survey. Multilevel model analyses were used to examine the effects of group and time on the outcome variables. ResultsMultilevel model analyses showed an overall significant time effect across all outcome variables in both groups. However, the group effects were not statistically significant across the outcome variables. ConclusionsBoth interventions significantly increased participants' self-management/HCT readiness, self-advocacy, and mindfulness over time. Mindfulness training may not bring additional benefits to the “ALL YOU NEED IS LOVE” education manual. Practice implicationsPediatric nurses and clinicians may utilize the self-directed “ALL YOU NEED IS LOVE” manual to increase self-management/transition readiness, self-advocacy, and mindfulness among adolescents with chronic kidney disease.

Translational research – Healthcare transition readiness, stress, and resilience among youth with chronic conditions and disabilities

The demands of chronic conditions and disabilities challenge children and their families to manage their chronic condition and disability on a daily basis as children grow and develop. Children and adolescents are challenged to learn self-management skills and are vulnerable to developing stress created by the interplay between their developmental needs and the demands of managing the chronic condition and disability (Christian, 2016a, 2016b, 2019). As children with chronic conditions and disabilities become adolescents, they gain independence in self-management from their parents.

Health care transition from pediatric to adult care: an evidence-based guideline

For consistent quality of treatment of young people with chronic health care needs, a structured health care transition (HCT) from pediatric medicine to adult medical care is essential. Currently, most countries have no guidelines on HCT based on systematic evidence research. To close this gap, guidance to support HCT was developed in Germany. Twenty-two experts in the management of adolescents and young adults with different chronic conditions and three patient representatives were invited to take part in the guideline group. Based on a systematic literature search recommendations for HCT were drafted. Where evidence was lacking, recommendations were developed using collective expert consensus. The consensus process was independently moderated using a Delphi approach. The final draft was reviewed and endorsed by all major German medical societies. The clinical recommendations provide guidance for all chronic somatic diseases. After assessment of HCT readiness, an individualized plan for HCT should be drawn up. Key elements here are a responsible coordinator, age-adapted patient education, involvement of caregivers, web-based interventions, joint visits, and a structured summary for the receiving physician. The aim is the gradual transfer of responsibility for disease management to the young person themselves. Conclusion: As only a few randomized controlled studies on HCT are available, evidence-based statements are possible for some but not all areas of HCT. However, this guideline may help to develop globally accepted standards. These standards should be established and implemented. The aim should be a reimbursement by individual national health systems to allow appropriate support for young people.What is Known:• Health care transition from pediatric to adult care is primarily organized in local settings, partly based on disease-specific guidelines.•There have been no national guidelines in Germany until now.What is New:• Here we present the general evidence-based guidelines of the German Association of Scientific Medical Societies for health care transition.• These might serve as a blueprint for further national or international health care transition guidelines.

Coping, Anxiety, and Health Care Transition Readiness in Youth with Chronic Conditions

PurposeTo explore the relationship between coping and health care transition readiness, and to examine whether anxiety is a mediator between coping and health care transition readiness. Design and methodsA sample of 174 youths with various chronic conditions (age 13.03 ± 2.02 years, 48.3% male) attending the 2018 Victory Junction Camp and their parents participated. Youths and parents completed measures to assess coping (Kidcope Checklist), anxiety symptoms (PROMIS Anxiety scale), and transition readiness (STARx Questionnaire) through Qualtrics online surveys. ResultsPositive coping was positively related to transition readiness in both youth and parent-proxy reports, while negative coping was negatively related to transition readiness in youth reports. Anxiety mediated the relationship of positive coping and transition readiness in parent-proxy reports, and the relationship of negative coping and transition readiness in both youth self-reports and parent-reports. ConclusionsCoping is an important factor in transition readiness. Furthermore, anxiety is an important mediator, and may be more influential in the relationship of negative coping and transition readiness. Practice implicationsPractitioners and health care providers can use these findings to promote the use of positive coping and reduce the use of negative coping, which in turn may improve outcomes for youth with chronic health conditions who are transitioning to adult health care services.