Endocrine Abstracts

Background : Transition Clinics (TCs) are specialized, multidisciplinary healthcare settings that support young people with chronic conditions as they move from pediatric to adult care. These clinics are considered essential in ensuring continuity of care, fostering self-management skills, and preventing adverse outcomes such as medication non-adherence and loss to follow-up. This study aimed to identify best practices in nurse-led TCs and determine key nurse roles contributing to high-quality transitional care.

Methods: This study used a mixed-methods approach consisting of semi-structured interviews with nurse specialists in six transition clinics and surveys among young adults. . Additionally, an integrative review analyzed the roles and responsibilities of nurses and nurse practitioners, highlighting their impact in the transition process.

Results: Nurse-led TCs incorporated individualized transition plans (ITPs), transition coordinators (often nurses/nurse practitioners), and warm handovers to create a structured and seamless transfer of care. These elements contributed to high levels of satisfaction among young adults and increased their trust in healthcare providers. Nurses played a multifaceted role in the transition process, offering personalized guidance and self-management support. The review identified eight critical nurse roles in transitional care: service coordinator, innovator, researcher, advocate, coach, educator, clinician, and liaison to the community. Despite the effectiveness of nurse-led TCs, challenges persist. Resource limitations, gaps in interdisciplinary collaboration, and barriers to fully integrating transitional care into routine practice remain significant concerns. Addressing these challenges requires greater institutional support, encouraging nurses to take up advanced roles, youth participation, and system-wide collaboration. This would help to optimize long-term patient outcomes and ensure equitable access to transitional care.

Conclusion: Nurse-led TCs are vital in facilitating smooth transitions, not only by managing medical transitions but also by empowering young adults and supporting families. By fulfilling diverse roles, nurses enhance the effectiveness of transitional care programs. However, addressing financial constraints, engagement difficulties, and collaboration gaps with primary and mental healthcare services is essential for further improvement.

Keywords: Transitional care, nurse-led clinics, transition clinics, nurse roles, self-management, young adults, nurse practitioners