Inclusive Transition

Increasing trends in the number of students with disabilities who transition from high school to college and career have been evidenced in the past 30 years. Transition support for students who have been included in secondary school classrooms is necessary to ensure successful outcomes. The purpose of this chapter is to present the evolution of transition support and two evidence-based transition planning approaches. The chapter also presents the laws that support transition at various points in the educational pipeline and suggests training and outcomes that might be provided for students and their families and educators. Inclusive education has done much to spur the need for change in the transition process. The approaches are available. They need to be implemented to support students to persist and succeed in post-secondary education and in the world of work.

Interactive Transition Support for Adolescents Living with HIV using Social Media (InTSHA): Research Protocol (Preprint)

BACKGROUND Adolescents living with perinatally-acquired HIV often have poor retention in care and viral suppression during the transition from pediatric to adult based care. OBJECTIVE To evaluate a mobile phone-based intervention, InTSHA: Interactive Transition Support for Adolescents Living with HIV using Social Media, among adolescents living with perinatally-acquired HIV as they transition from pediatric to adult care in South Africa. METHODS InTSHA uses encrypted, closed group chats delivered via WhatsApp to develop peer support and improve communication between adolescents, their caregivers, and healthcare providers. The intervention is based on formative work with adolescents, caregivers, and healthcare providers and builds on several existing adolescent support programs as well as the Socioecological Model for Adolescent and Young Adult Readiness to Transition (SMART). The final InTSHA intervention involves ten modules conducted weekly through moderated WhatsApp group chats with adolescents and separately with their caregivers. We will randomize 80 South African adolescents living with perinatally-acquired HIV who are aware of their HIV status and aged between 15 to 19 years to receive either the intervention (n=40) or standard of care (n=40). RESULTS We will measure acceptability of the intervention as primary outcome and evaluate feasibility and preliminary effectiveness for retention in care and viral suppression after completion of the intervention and at least six months after randomization. In addition, we will measure secondary outcomes evaluating the impact of the InTSHA intervention on peer support, self-esteem, depression, stigma, sexual education, connection to healthcare providers and transition readiness. CONCLUSIONS If successful, the intervention will be evaluated in a fully powered randomized controlled trial with a larger number of adolescents from urban and rural populations to further evaluate the generalizability of InTSHA. CLINICALTRIAL ClinicalTrials.gov Identifier: NCT03624413

Person-centred care transitions for people with stroke: study protocol for a feasibility evaluation of codesigned care transition support

BackgroundCare transitions following stroke should be bridged with collaboration between hospital staff and home rehabilitation teams since well-coordinated transitions can reduce death and disability following a stroke. However, health services are delivered within organisational structures, rather than being based on patients’ needs. The aim of this study protocol is to assess the feasibility, operationalised here as fidelity and acceptability, of a codesigned care transition support for people with stroke.MethodsThis study protocol describes the evaluation of a feasibility study using a non-randomised controlled design. The codesigned care transition support includes patient information using videos, leaflets and teach back; what-matters-to me dialogue; a coordinated rehabilitation plan; bridged e-meeting; and a message system for cross-organisational collaboration. Patients with stroke, first time or recurrent, who are to be discharged home from hospital and referred to a rehabilitation team in primary healthcare for continued rehabilitation in the home will be included. One week after stroke, data will be collected on the primary outcome, namely satisfaction with the care transition support, and on the secondary outcome, namely health literacy and medication adherence. Data on use of healthcare will be obtained from a register of healthcare contacts. The outcomes of patients and significant others will be compared with matched controls from other geriatric stroke and acute stroke units, and with matched historic controls from a previous dataset at the intervention and control units. Data on acceptability and fidelity will be assessed through interviews and observations at the intervention units.Ethics and disseminationEthical approvals have been obtained from the Swedish Ethical Review Authority. The results will be published open-access in peer-reviewed journals. Dissemination also includes presentation at national and international conferences.DiscussionThe care transition support addresses a poorly functioning part of care trajectories in current healthcare. The development of this codesigned care transition support has involved people with stroke, significant other, and healthcare professionals. Such involvement has the potential to better identify and reconceptualise problems, and incorporate user experiences.Trial registration numberhttp://www.clinicaltrials.gov id: NCT02925871. Date of registration 6 October 2016.Protocol version1.

The development of the rehabilitation community transition support team as a response to COVID-19

Background/aims The rehabilitation community transition support team was created as a response to the COVID-19 pandemic, resulting in faster discharges from the inpatient rehabilitation service. The aim of this evaluation was to explore the perspectives of staff and patients on their experience of the rehabilitation community transition support team. Methods Staff and patients in the new team were interviewed using semi-structured interviews. The data were analysed using thematic analysis. Results Staff interviews generated seven main themes: positive staff experiences; defining the ‘team’; mode of working; link role for the team; technology; relationships with patients; and support from colleagues. The patient analysis generated five themes: positive experiences of the rehabilitation community transition support team; relationship with rehabilitation community transition support team worker; mode of working; handling the hurdles of discharge; and defining the ‘team’. There were crossovers of staff and patient themes, particularly surrounding around face-to-face visits, defining the team and relationships. Patients indicated that contact with the community team helped them to overcome both practical and emotional hurdles of discharge. Conclusions The presence of a team supporting the transition from hospital to a community setting may be helpful for people who have been discharged.

Transfer and transition referrals of patients with intellectual disability from children's services to adult community learning disability teams

AimsThe audit aimed to assess if patients under the care of children's services in Wessex were transferred at the appropriate age and whether transition referrals to Community Learning Disability teams (CTLD) occurred timely. It also aimed to look at how many patients underwent transitions in a three month period, and if their transition support plan (TSP) was completed. A transition support plan should include chronological information on psychopharmacology, psychotherapy, and social support measures. Patients should be referred between the ages of 17–19 but require a justification after 18 years of age.MethodThe BI team was contacted to provide all IDs for patients referred within a three month period between the ages of 17–19. The BI team provided 42 patients with their ID. Patients discharged from services within a short time span were excluded for the following reason: inappropriate referral (9pts), discharged after 1st assessment (6pts), internal discussion (6pts), only referred to Autism team (4pts), moved out of area (1pts). From the initial 42 patients, 16 patients were analysed using the collection tool.Result4/16 had a TSP, and only two had a complete TSP and transitioned in another trust and were inter-team referrals.CAMHS services referred 1/16 patients.Psychotropic medication was prescribed to 12/16 prior to or on time of referral, but only two patients had a complete psychotropic medication history.8/16 patients' referral was commenced prior to their 18th birthday, and no information was provided for delay in transfer.Health records did mention psychotherapy, but apart from 2/16 TSP records, no additional information was available on the modality.ConclusionPatients with Intellectual Disability face challenges when transferring from children to adult services. Insufficient referral information may have a detrimental impact on patients wellbeing and long-term care.Access to a patient's chronological journey through the different children's services allows Adult CTLD health professionals to provide effective care. Historical psycho-social and pharmacological interventions provide a reference point for future interventions.Concerns included: limited information on most TSP regarding psycho-social and psychotropic treatments, lack of access to CAMHS/CHYPS paperwork and ineffective inter-trust communication for transition patients.This project highlighted the average number of transition cases in 3 months. It led to changes to the transition pathway, as awareness was raised in trust and CCG meetings to improve patient outcome. CTLD created the new role of transition facilitators to support children's services. They sit in meetings before patients transition referrals.