Establishment of hospital-to-hospital based health care transition system for adolescents

Abstract

Due to advances in pediatric medicine, the mortality rate of childhood-onset chronic diseases has reduced and the number of adult patients with such diseases has increased. Although pediatricians cannot provide appropriate medical care to adult patients, they often remain in pediatric care units without appropriate support of health care transition. Until now, various efforts have been made to support health care transition for adolescents to adult care units, but most of them proceed from the pediatric side, not the adult side.

The purpose of this study is to establish an accurate health care transition system for adolescents with multi-organ complex or intellectual disabilities, where it is difficult to transition to adult care units. First, a transition team (composed of general physicians, pediatricians, nurses and social workers, etc.) for receiving patients is organized at the National Center for Global Health and Medicine (NCGM), and the team (called "adult team") will cooperate with hospital divisions in the NCGM. The transition team (called "child team") of the National Center for Child Health and Development (NCCHD) will support the adult team. Then, we will adapt the health care transition system to other national centers.

We will use a web conferencing system and online medical care system for the collaboration. With support from the child team of NCCHD at each national center, we will establish a new support system that does not rely on referral letters. Eventually, we will share the support system for the health care transition for adolescents with the "Health Care Transition Support Centers" of each prefecture. We support the smooth implementation of the health care transition system for adolescents throughout the country. In addition, based on these experiences, we plan to start developing a "Health Care Transition Support app" that includes a web conferencing system and an online medical care system.

Perspectives

This research will establish a new hospital-to-hospital based health care transition system for patients who are difficult to transition to adult care units.

Comments from principal researcher

For the last five years, I have been working on health care transition support in the National Center for Child Health and Development (NCCHD). The most important point is what is the best medical care for adult patients who remain in pediatric care units. This point is very important when we encounter many difficulties. Japanese national centers are fully equipped with advanced medical care and associated networks. Therefore, it is possible to deal with patients with severe illnesses or medical conditions, and we can pursue the best health care transition for adolescents with the cooperation of national centers.