title: Implementation of an inter-agency transition model for youth with spina bifida.
abstract: BACKGROUND
  To address gaps in transfer of care and transition support, a paediatric hospital and adult community health care centre partnered to implement an inter-agency transition model for youth with spina bifida. Our objective was to understand the enablers and challenges experienced in the implementation of the model.
  
  
  METHODS
  Using a descriptive, qualitative design, we conducted semi-structured interviews, in-person or over the phone, with 12 clinicians and nine key informants involved in implementing the spina bifida transition model. We recruited all 21 participants from an urban area of Ontario, Canada.
  
  
  RESULTS
  Clinicians and key informants experienced several enablers and challenges in implementing the spina bifida transition model. Enablers included dedicated leadership, advocacy, funding, inter-agency partnerships, cross-appointed staff and gaps in co-ordinated care to connect youth to adult services. Challenges included gaps in the availability of adult specialty services, limited geographical catchment of adult services, limited engagement of front-line staff, gaps in communication and role clarity.
  
  
  CONCLUSIONS
  Although the transition model has realized some initial successes, there are still many challenges to overcome in transferring youth with spina bifida to adult health care and transitioning to adulthood.
authors.affiliation: Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.|Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Lindsay
authors.affiliation: Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.
authors.forename: H
authors.initials: H
authors.lastname: Cruickshank
authors.affiliation: Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.|Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
authors.forename: A C
authors.initials: AC
authors.lastname: McPherson
authors.affiliation: Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Maxwell
mesh_terms: D000293:Adolescent; D003153:Community Health Services / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D006233:Persons with Disabilities / Q000706:statistics & numerical data*; D017598:Efficiency, Organizational; D005260:Female; D006801:Humans; D008297:Male; D009864:Ontario / Q000453:epidemiology; D036301:Qualitative Research; D016135:Spinal Dysraphism / Q000453:epidemiology / Q000523:psychology / Q000534:rehabilitation*; D060305:Transition to Adult Care / Q000458:organization & administration*; D014505:Urban Population; D055815:Young Adult
keywords: adolescent; continuity of care; inter-organization partnership; rehabilitation; spina bifida; transition