Table 2

Summary of findings

Triple Aim domains
Transition intervention/programmePatient conditionLocationPrimary care engagementStudy designOutcomes/resultsQuality score32Experience of care ◊Population health ○Cost □
Pilot programme aimed at improving continuity of care by helping adolescents identify an adult medical home. Consists of 3 components including a tour of SCD programmes, lunch discussion with staff, and team scheduling patient's 1st visit to the adult programme. Attendance records consulted and patient/parent and healthcare provider feedback obtained from surveys.33SCDTennessee, USACase manager facilitated 1st appointment to help establish relationship with adult medical home/provider of patients' choice.Retrospective cohort studyOverall participation
  • 34 of the 83 agreed to participate (41%) □

  • Proportion of participants who fulfilled 1st appointment with an adult haematologist (74%) vs non-participants (33%) in 3 months □

Satisfaction: programme rated as either helpful or very helpful
  • Patient/parent satisfaction (↑) ◊

  • Provider satisfaction (↑) ◊

5 Academic paediatric and adult health centre teams adopted a 2-year learning collaborative to implement ‘Six Core elements of Healthcare Transition’. Teams consisted of a physician and a transition care coordinator and utilised the Health Care Transition Index to assess programme progress in implementing the Six Core Elements.34Chronic physical, develop-mental and mental health conditionsDistrict of Columbia, USAStudy set in 5 large primary care practices. 2 Were in adolescent clinics, 1 in a paediatric clinic, 1 in a family medicine resident clinic, and 1 in an internal medicine clinic.Time series comparative study(compared results of transition index at 3 points in time over a 22-month period)Improvements in 6 quality indicators of transition:
  • Development of an office transition policy (↑) ○

  • Staff and provider knowledge and skills related to transition (↑) ○

  • Identification of transitioning youth registry (↑) ○

  • Transition preparation of youth (↑) ○

  • Transition planning (↑) ○

  • Transfer of care (↑) □

A feasibility and acceptability study of the Maestro Project—community-based administrative support and systems navigation service. Patients were contacted biannually to enquire about access to care, services, health status associated with diabetes complications and offered follow-up support.35Type 1 diabetesManitoba, CanadaA navigator facilitated referrals connecting patients to family physicians and other support when requested.Uncontrolled cohort studyAttendance/participation rate
  • 373 Of the 473 (78.9%) □

  • Project referrals and community connections (↑) □

  • Of the 373 participants, 127 requested 230 community contacts for assistance to access care, education or optometry services □

  • 34 Contact numbers given for family physician care □

  • 121 Contacts to reconnect with diabetes education and counselling services □

  • 203 Requests for more information/support □

  • SCD, sickle cell disease.