A chronic care model for spina bifida transition.

Area of Science:

• Pediatric Health
• Chronic Condition Management
• Healthcare Transition

Background:

• Adolescents and young adults with spina bifida (AYASB) require tailored transition care.
• Current transition models face challenges in addressing diverse AYASB needs.
• Effective transition planning is crucial for long-term health outcomes.

Purpose of the Study:

• Identify AYASB transition program needs from literature and local data.
• Analyze existing AYASB transition care models.
• Demonstrate the application of the Chronic Care Model (CCM) in an SB transition clinic.
• Examine the feasibility of adapting the CCM-based model.

Main Methods:

• Literature review of AYASB transition care needs and models.
• Analysis of a spina bifida (SB) transition clinic's program development.
• Application of the Chronic Care Model (CCM) framework.
• Assessment of model adaptability for other SB clinics.

Main Results:

• Identified key AYASB transition needs: chronic condition management, self-management, care coordination, and navigation.
• Highlighted advantages and limitations of existing transition care models.
• Demonstrated successful implementation of a CCM-based SB transition clinic program.
• Found the CCM model feasible for adaptation in other SB clinics.

Conclusions:

• A spina bifida-specific transition clinic utilizing the CCM facilitates complex chronic care management and transition planning for AYASB.
• Further research is needed to evaluate health outcomes associated with CCM implementation for SB transition.
• The CCM offers a structured framework for comprehensive AYASB transition care.