Transition of Care in Serbia: Current State and How to Establish an Effective Model

In Serbia, the transition of patients from the pediatric to the adult healthcare system is not uniformly regulated. There are guidelines and good practices that are applied in larger centers. Due to the lack of a formal protocol, the transition is often referred to as a “transfer,” i.e., the transition is carried out abruptly at the age of 18. Large pediatric clinics are gradually introducing transition programs for chronic patients. The leading challenges we face are treatment discontinuation, insufficient patient education, and poor communication between pediatric and adult doctors. The imperative is a highly effective model that defines a structured, multidisciplinary approach that includes medical, psychological, and social preparation of the patient. Such an approach would ensure the goals of an effective transition. In the first place, continuity of treatment, patient independence in disease management, and the risk of losing the patient from the system would be minimized. Key elements of an effective transition model include the formation of a multidisciplinary team, early involvement of patients, an individual transition plan, transition documentation, introduction to an adult doctor, and monitoring after the transfer. Practical measures to achieve an effective model at the institution level are the formation of a transition team, appointing a coordinator, identifying patients who will transition to the adult system in the coming years, creating a standardized form and transition report, introducing gradual education of patients and parents, establishing cooperation with the adult team and organizing joint examinations, and maintaining registers of patients in transition. Establish periodic monitoring and evaluation of the program—clinical outcomes, continuity of treatment, and patient satisfaction. The ultimate transition is not an administrative transfer, but a continuous process of 3–5 years, which includes medical, psychological, and social dimensions, which significantly reduces the risk of losing a patient from the system.