Key Issues in Transition When Should Patients Begin the Process of Transition and When to Transfer? The timing of entry from a pediatric clinic into a service responsible for transition, and the subsequent transfer to adult clinics, will vary according to the provision of local services and the individual needs of the patient It is important, however, that transition and transfer occur in a predictable and planned manner Referral to the clinics or programs responsible for transition should ideally begin by 12 years of age Compared to older ages, at the age of 12, individuals are more susceptible for suggestions from adult people and for building up a trusting relationship with new healthcare professionals.17 Attendance at such clinics involves a change in approach from the typical pediatric cardiac clinic Parents should continue to attend, but there should be greater emphasis on communication with the adolescent, including opportunities for confidential oneon-one discussion with doctors, nurses, and other relevant counselors The approach to communication needs to evolve as the teenager grows older, with provision for discussion appropriate to age and maturity Transfer to the adult clinic most commonly occurs at the age of 18 years or on completion of schooling The timing, however, should be flexible so as to meet the needs of the patient For example, if a patient has developmental delay, or multiple medical problems under active follow-up in the pediatric hospital, transfer may need to occur at an older age Patients should understand that transfer to adult care is a natural process and part of growing up In general, adolescents deem it appropriate to move their care to adult-focused facilities.18 However, parents are often more hesitant because they strongly rely on the trusting relationship that they have built up with the pediatric care providers.18 Early discussion, and agreement on an age of transfer, removes the frequent anxiety of families that expert care is being lost, and makes transfer to adult care a development to be viewed optimistically In some medical systems, provision of adult services for grown-up patients with congenitally malformed hearts is not yet available at a level comparable to that provided during childhood In these cases, delay of transfer is clearly advisable Where Should Care Be Undertaken? Availability of clinical resources will determine the location of the transition clinic Ideally, this should be within the pediatric hospital, as this makes the first move from the pediatric clinic less traumatic to the patients and their families Those staffing the clinic have the opportunity, during several visits over years, to organize the subsequent transfer to adult care, which may need to be to a different hospital Facilities for in-patient care should be designed around the needs of young people, and ideally should be separate from pediatric and adult wards, with a different atmosphere and focus A dedicated adolescent environment for patients with a range of medical conditions can work well for the needs of cardiac patients This permits provision of facilities, including Internet access, a study area, television, a social area, and kitchen facilities The adolescent ward should be organized by staff with special awareness and training in the issues of this age group Who Should Be Involved in Transitional Care? The balance of staffing for the transition clinic depends on local resources It is, however, essential that members of the team providing pediatric care and of the team looking after their future needs as adults with cardiac problems are both involved.19 This provides an opportunity for discussion between teams of the specific medical needs of the patient, as well as creating a visible connection for the patient and their families Specialist nurses play a crucial role in successful transition by taking up the role of transition coordinator.20–23 They should have experience in the needs of adolescents and young adults with congenitally malformed hearts, and should have received training in counseling There should be facilities for the specialist nurses/transition coordinators to consult with the patient separately from the doctor, as this encourages early discussion of sensitive problems and anxieties The specialist nurses/transition coordinators frequently are the main contact with the patient and his or her family, developing a unique relationship with them How Should Transitional Care Be Provided? Transitional care comprises several interacting components Therefore it is considered to be a complex intervention24 and ought to be developed from a programmatic point of view This programmatic approach assures that transitional care is provided in a systematic and structured way Transition programs for young persons with chronic conditions in general, and with congenital cardiac disease in particular, are developed and tested Some transition programs are extensive and require a lot of time, whereas other transition programs can been seen as brief interventions.25 Core Components of Transition Programs To date, some transition programs have been described in the literature.20–23,26,27 These transition programs are common practice in the respective hospitals,20–23 or are under investigation as part of an effectiveness study.26,27 Core components of transition programs have been described.27 Transition Coordinator A transition coordinator is an indispensable component of successful transition programs Transition coordinators is often a specialist nurse, advanced practice nurse, clinical nurse specialist, or nurse practitioner The transition coordinator often is the main point of access for patients and their families when it comes to transition, but also coordinates the multiprofessional team pertaining to delivering transitional care He/she assures continuity of care; supports the youth and their parents throughout the transition process; liaise the hospital/clinic with the community; serves as a patient advocate; safe-guards family- and personcentered care; and provides youth and parent education.28 Transition Plan For each individual patient who enters the transition process, a written transition plan should be developed A transition plan documents the needs of the young person and his/her parents; addresses the health, psychosocial, and educational issues; details the objectives of the transition; and comprises a timing of the planned meetings and the foreseen moment of transfer The transition coordinator, together with the adolescent, will be in charge of determining which topics are important to discuss during the transition meetings and which goals related to patient development and functioning are to be advanced.27 The transition plan is a working document that evolves over the course of the transition process ...Availability of clinical resources will determine the location of the transition clinic Ideally, this should be within the pediatric hospital, as this makes the first move from the pediatric clinic less traumatic to the patients and their families... Facilities for in-patient care should be designed around the needs of young people, and ideally should be separate from pediatric and adult wards, with a different atmosphere and focus A dedicated adolescent environment for patients... The balance of staffing for the transition clinic depends on local resources It is, however, essential that members of the team providing pediatric care and of the team looking after their future needs as adults with cardiac problems are both