Transition can be defined as a multidimensional, active process that is age and developmentally appropriate and attends to the medical, psychosocial, and educational/ vocational needs of adolescents as they move from childto adult-centered services. The key principles are summarized in Table 1 and essentially represent care for adolescents that is age and developmentally appropriate. Transitional care should be an integral part and a recognized core quality criterion of all pediatric and adult rheumatology services. This review will update the reader on the key components of transitional care with particular reference to juvenile idiopathic arthritis (JIA) and includes a discussion regarding multidisciplinary involvement, service delivery models, evaluation, and future research.
Key Components of a Transitional Care Program
Written policy. One of the fundamental components of transition is a written policy, developed and agreed on by all key participants, to 1) ensure consensus, 2) ensure mutual understanding of the processes involved, and 3) provide a structure for evaluation and audit. In practice, however, such policies are not developed (1) and/or are not adhered to (2).
An important aspect of such policies is consideration of the transition timeline. An overriding principle of transition is that of flexibility, which acknowledges both the heterogeneity of adolescent developmental processes and the potential impact of chronic illness on such processes. Developmental delay in patients with JIA has been reported not only with respect to physical growth (3) but also with respect to psychosexual, social, and vocational developmental milestones (4 -8). Data from a UK study supported an early start to transition, with 11-and 14-yearold patients with JIA showing maximum improvement in disease knowledge after 12 months of participation in a transitional care program, which was significantly greater than that of 17-year-old patients at baseline ( 9). In agreement with the UK study, Hait et al advocated starting a program at age 11-13 years for young persons with inflammatory bowel disease, with a timeline extending to age 23 years (10). In a US-based study, transition planning was reported as having to be in place by age 12-14 years to ensure vocational success in particular (11).
The core content of a transition policy for a rheumatology department is detailed in Table 2. The author's departmental transition policy is available at www.dreamteamuk.org.
Coordinator and key worker role.
A staff member who is specifically designated as the transitional care program coordinator is vital to ensure both implementation and regular review, update, and evaluation. This is particularly pertinent in view of the frequently reported poor communication both between agencies and families and within agencies (12). A key worker for individual patients, particularly those with complex needs, is also important for success, albeit challenging to resource. In a multicenter