Digital Delivery of Person-centered Transitional Care

"The STEPSTONES transition program is an 8-component intervention designed to support adolescents with chronic conditions transitioning to adult care. It includes: a transition coordinator (TC), education about the condition, phone support, guidance on transitioning to adult care, parental guidance, peer meetings, a personalized transition plan, and the actual transfer to adult care. The intervention is implemented in five steps, starting with outpatient visits and culminating in the transfer to adult care. Delivered via the Mitt vårdmöte digital platform, the program includes the HEADDDSS adolescent health interview and is conducted by trained specialized nurses."