Transition and young adults – what social work for young adults needs and how transition can work.
Social workers have a significant role to play in supporting young adults (16 – 30 years) who are living with renal disease. The purpose of the role is multifaceted. It is to provide extra support for this vulnerable patient group to navigate transition from paediatric to adult services, to improve their social and clinical outcomes and to assist with any psychosocial issues that present that impact their renal health. This can include reducing DNA clinic rates and admissions, improving treatment adherence, and empowering patients to become more independent and take control of their conditions.
Social workers can support patients with a range of different issues in a way that is streamlined for each individual patients’ needs. This can be done through virtual mediums as well as meeting patients face-to-face in clinic appointments, ward visits and 1:1 appointments.
The main areas that Social Workers can support with are:
- Clinic attendance – reminders and accompanying to clinic
- Medication concordance – reminders and supporting patients to find ways to integrate taking their medications into their schedule, liaising with medical team regarding delivery and collection of medications
- Liaison with medical team – mediating between medical team and patients regarding any health concerns and maintaining patient engagement
- Housing – Guidance to navigate system, advocacy with council and other agencies, signposting to specialist services when necessary
- Benefits – Guidance to navigate system, advocacy and provision of supporting documentation, signposting to specialist services when necessary
- Education/employment – Advice, advocacy and providing supporting documentation, linking up with specialist services
- Sexual health – education, linking up with specialist services, support arranging treatment
- Mental health – Emotional support, linking up with specialist services
- Adjustment to diagnosis – emotional support, educational support
- Social support – linking up with KCUK (kidney care UK) peer support and residential trip, running young adult social group alongside clinic
- Transition – facilitating transfer of care from paediatric to adult service
A significant part of the work involves assisting young patients with their transition from paediatric to adult services. This should involve meeting patients multiple times when they are 16/17 years old in their paediatric care centre clinics with their care team, orientation to the adult care centre as well as a formal clinic in the adult setting just before their 18th birthday. Good communication with the paediatric care team until the patient’s 18th birthday is essential to ensure relevant information is relayed and they transfer to adult services feeling comfortable, safe and to a team who knows them well.