Effectiveness of Transitional Care in Inflammatory Bowel Disease; Development, Validation, and Initial Outcomes of a Transition Success Score - Scorecard - MDSpire
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Effectiveness of Transitional Care in Inflammatory Bowel Disease; Development, Validation, and Initial Outcomes of a Transition Success Score
By
Martha A C van Gaalen
Merel van Pieterson
Petra Waaijenberg
Angelika Kindermann
Victorien M Wolters
Alie Dijkstra
Herbert van Wering
Margreet Wessels
Lissy de Ridder
Dimitris Rizopoulos
C Lauranne A A P Derikx
Johanna C Escher
Colitis (KiCC) Working Group for Collaborative Paediatric IBD Research in the Netherlands the Dutch Initiative on Crohn and Colitis (ICC) and Dutch Nurses Network Inflammatory Bowel Disease (NIBD) the Kids with Crohn’s
Clinical Scorecard: Assessing the Impact of Transitional Care on Inflammatory Bowel Disease: Creation, Validation, and Preliminary Results of a Transition Success Score
At a Glance
Category
Detail
Condition
Inflammatory Bowel Disease (IBD), including Crohn’s disease and ulcerative colitis
Key Mechanisms
Transition from pediatric to adult healthcare focusing on patient independence, disease knowledge, self-management skills, and navigation of adult care system
Target Population
Young adults (aged 18-25 years) with IBD transitioning from pediatric to adult healthcare
Care Setting
Multicenter adult healthcare settings including 7 Dutch hospitals
Key Highlights
Development and validation of a quantitative Transition Success Score (TSS) based on Top 10 outcome items identified via international Delphi study.
TSS evaluates transition success by measuring patient independence, decision-making, and satisfaction 9-15 months post-transfer.
Higher disease burden, exacerbations during/after transfer, and certain personality profiles correlate with lower transition success scores.
Guideline-Based Recommendations
Diagnosis
Use validated outcome measures like the Transition Success Score (TSS) to assess transition effectiveness in IBD patients.
Management
Implement structured transition programs to improve self-management skills, disease knowledge, and quality of life in young adults with IBD.
Empower patients with autonomy, self-efficacy, and disease knowledge during transition period.
Monitoring & Follow-up
Assess transition success 9-15 months after transfer using TSS scored by healthcare providers, patients, and caregivers.
Monitor for disease exacerbations and patient independence as indicators of transition challenges.
Risks
High disease burden and exacerbations during or after transfer increase risk of unsuccessful transition.
Certain personality profiles may predispose to lower transition success.
Patient & Prescribing Data
Young adults with IBD transitioning from pediatric to adult care
Transition success is linked to patient independence and self-management rather than solely disease-specific factors; structured transitional care improves outcomes.
Clinical Best Practices
Engage multidisciplinary teams including pediatric and adult gastroenterologists and specialized nurses in transition planning.
Use validated tools like the TSS to quantitatively assess transition outcomes.
Focus on developing patient decision-making and self-management skills as primary goals of transition.
Involve caregivers in supporting gradual patient independence.
Consider patient quality of life as an important validation measure though not included in TSS.
by Martha A C van Gaalen, Merel van Pieterson, Petra Waaijenberg, Angelika Kindermann, Victorien M Wolters, Alie Dijkstra, Herbert van Wering, Margreet Wessels, Lissy de Ridder, Dimitris Rizopoulos, C Lauranne A A P Derikx, Johanna C Escher, Colitis (KiCC) Working Group for Collaborative Paediatric IBD Research in the Netherlands the Dutch Initiative on Crohn and Colitis (ICC) and Dutch Nurses Network Inflammatory Bowel Disease (NIBD) the Kids with Crohn’s, Patrick F van Rheenen, Sarah T A Teklenburg, Fiona D M van Schaik, Janneke C van der Woude, Jildou Hoekstra, Marleen de Leest, Carla Bakker, Elvira M E Besuijen-Laterveer, Esther Adriaanse, Jolien Wisse, Marloes Heida, Pamela Hurkmans, Nynke Boontje, Tessa Z Toonen, Wendy Heida
