Samenvatting

Background and purpose
A generic, structured transitional care pathway dedicated to patients in the academic setting is currently lacking. This study aimed to identify the key factors influencing a successful transition from pediatric to adult care for adolescents and young adults and to develop a generic, hospital-wide Blueprint for transitional care in such settings, using intervention mapping as the guiding method
Method
A combination of literature review, focus groups, and semi-structured interviews was carried out, leading to a logical model of the problem in a situation where transition is poorly managed or when transitional care is absent in the academic setting. This model helped outline the behavioral objectives, determinants, and change goals, which were then transformed into practical applications. Key interventions were identified and integrated into a coherent Blueprint for transitioning from pediatric to adult healthcare. A Transition Programme Development Working Group and a Transition Patient Council have been involved in every step of the Blueprint's development.
Results
The Blueprint for structured transitional care promotes pediatric and adult collaboration through eight key interventions, including two joint consultations, one double-time consultation, and appointing a transition coordinator who annually prepares and updates individual transition plans.
Conclusion
Intervention mapping helped designing a structured, personalized Blueprint as an evidence based example for transitioning patients with rare and chronic conditions in an academic hospital. The Blueprint described in this article is currently being implemented and evaluated across six pilot departments. If proven effective, it can be disseminated more widely.