Grant: Project Grant

Transition to adult care is a challenging and complex time for adolescents and young adults with chronic health conditions. Many patients and families struggle to adapt to adult health care settings, and report difficulties accessing needed services to manage their health conditions into adulthood. Similarly, adult care providers feel unprepared to care for transferred pediatric patients with chronic health conditions, and lack necessary resources and time to manage the complexity and diversity of their psychosocial and medical needs. As a result, transferred patients experience difficulties navigating an unfamiliar adult health care system, and some experience significant and irreversible health deterioration. These gaps in transitional care undermine the long-term benefit of significant investments made in child health. Limited studies to date evaluate the effectiveness of interventions to improve transitional care across multiple health care settings. We propose to evaluate the impact of a patient navigator service to coordinate transition to adult care of adolescents and young adults living with a chronic health condition in Alberta. Our primary outcome of interest is emergency room/urgent care visits. We will also conduct interviews and focus groups to develop an in-depth understanding of participants' and their families' perceptions about the patient navigator role to reduce modifiable barriers to care. We will also create a comprehensive cost model to determine the net health care cost impact attributable to the patient navigator intervention. This study will provide urgently needed data to guide pediatric and adult health care providers and policy makers regarding optimal transitional care delivery and will benefit the growing population of young adults living with chronic health conditions.