From research to innovation: a breakthrough in transitional care for adolescents with chronic conditions

Introduction: In the Netherlands, adolescents with chronic conditions are often ill prepared for their transition to adult care. Services are not geared toward adolescents’ needs and preferences. To bridge these gaps, a four-year innovation programme, On Your Own Feet Ahead, was started in 2008. Aim: To provide integrative health care services and appropriate transitional care to adolescents (12–25 years) with somatic chronic conditions. The programme focuses on the establishment of independent health behaviours, increasing of self-management skills and improving the organisation of transitional care. Description: Using a breakthrough approach, ten multidisciplinary pilot teams from hospitals and rehabilitation centres in the Netherlands implemented and evaluated a number of interventions and policy changes to improve transitional care, including the use of a transition coordinator, clinical pathways and individual transition plans. In the next phase of implementation, best practices will be spread nation-wide. Discussion: Despite considerable difficulties in finding local commitment and bridging cultural and organisational gaps, most teams succeed in establishing structural change and new partnerships. To facilitate changes, more commitment on national policy level seems required. Conclusion: In the pilot phase, the action-oriented breakthrough approach facilitated structural improvements of transitional care. This is promising for further dissemination.