SMART—Readiness for Transition to Adult Care Model

Attention to the time of transition from pediatric to adult healthcare and the best way to facilitate the transition has become increasingly important in recent decades due, in part, to the growing number of children and youth with special healthcare needs surviving to adulthood. To address this issue, in 2011 the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians coauthored a clinical report providing an algorithm for providers to implement best practices for the transition of patients both with and without special healthcare needs.

The report emphasizes that transition is a multifactorial process that requires the engagement of the patient, the family, and healthcare providers. Noting that the “algorithm and guidelines were developed in the absence of theoretical models and evidence-based assessment tools and interventions,” researchers recently conducted a study to fill the gaps in transition research. The current study used a mixed-methods participatory approach with patient, parent, and provider (PPP) stakeholders to validate the Social-Ecological Model of Adolescent and Young Adult Readiness to Transition (SMART), a newly developed model. The patients were adolescent and young adult survivors of childhood cancer 16 to 28 years of age. Results of the study were reported online in JAMA Pediatrics [doi:10.1001/jamapediatrics.2013.2223].

Whereas most research on transition focuses on patient disease knowledge and skills, SMART considers additional indicators of transition readiness, attends to multiple stakeholders perspectives, and distinguishes between variables more and less amenable to change within the context of clinical settings and multidisciplinary teams. SMART was informed by relevant research on transition, disease management, and adjustment to pediatric chronic illness, related theoretical models, and expert clinical opinion on transition readiness from providers in adolescent medicine and oncology (including physicians, nurses, and psychologists).

The current study was conducted at a large mid-Atlantic children’s hospital. Patients and parents in the study participated in focus groups; providers participated in individual semi-structured interviews. The validity of SMART was assessed in 3 ways: (1) ratings on importance of SMART components for transition readiness using a 5-point scale (0-4; ratings >2 support validity); (2) nominations of 3 “most important” components; and (3) directed content analysis of focus group/interview transcripts.

The qualitative data provided support for all SMART components, with minor modifications to definitions of components. Quantitative ratings met criteria for validity and stakeholders endorsed all components as important for transition. The PPP stakeholders endorsed SMART as comprehensive and applicable to their experiences with transition.

Limitations to the study cited by the authors included (1) the participants being primarily middle or high income, (2) nearly all of the providers interviewed practiced in the same pediatric setting, (3) the content analysis required an informed coder who may have been biased to find more supportive than nonsupportive evidence, (4) results from questionnaires administered after the interview or focus group were reflective of the discussions, and (5) the focus on pediatric oncology may limit the generalizability of the findings.

In conclusion, the researchers stated, “SMART represents a comprehensive and empirically validated framework for transition research and program planning, supported by survivors of childhood cancer, parents, and pediatric providers. Future research should validate SMART among other populations with special healthcare needs.”—Tori Socha

SMART—Social-Ecological Model of Adolescent and Young Adult Readiness to Transition

Preexisting Factors (objective factors less amenable to intervention)

• Sociodemographics/Culture

• Access/Insurance

• Medical Status and Risk

• Neurocognition/IQ

Modifiable Variables (subjective factors more amenable to intervention)

• Knowledge

• Skills/Self-Efficacy

• Beliefs/Expectations

• Developmental Maturity (patient only)

• Goals/Motivation

• Relationships/Communication

• Psychosocial/Emotions