AIM First, to understand the barriers to achieving effective transition and the supports required from the perspective of parents and carers, adolescents with intellectual disability and/or autism spectrum disorder and co-existing mental health disorders (often termed 'dual disability'), and those who provide services to this group. Second, to develop an informed model of shared care to improve the transition of adolescents with dual disabilities. METHOD Carers and a young adult with a dual disability were surveyed about their experience of transition care. Other key stakeholders including paediatricians, general practitioners, and policy makers were also interviewed. These data informed the model of care. RESULTS Paediatricians and general practitioners reported difficulties establishing working relationships to foster smooth transitions, and carers reported lacking a regular general practitioner with adequate expertise to care for people with dual disabilities. A process of shared care between paediatricians and general practitioners was developed and initiated by a dedicated transition manager, who assisted with care coordination and service linkages. Standardized clinical assessment tools were also introduced to determine patient and carer support needs. INTERPRETATION This study highlights the potential to improve transition outcomes for adolescents with dual disabilities and their carers through early transition planning, consistent methods of assessing patient and carer needs, and shared care.

中文翻译：

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为患有智力障碍和/或自闭症谱系障碍以及精神健康合并症的青少年制定无畏无惧的过渡模式

目标 首先，从父母和照顾者、患有智力障碍和/或自闭症谱系障碍以及共存心理健康障碍（通常称为“双重残疾”）的青少年的角度了解实现有效过渡的障碍和所需的支持，以及为这个群体提供服务的人。第二，开发共享照料的知情模式，以改善双重残疾青少年的过渡。方法 对护理人员和一名患有双重残疾的年轻成年人的过渡护理经历进行了调查。还采访了其他主要利益相关者，包括儿科医生、全科医生和政策制定者。这些数据为护理模式提供了信息。结果 儿科医生和全科医生报告说难以建立工作关系以促进平稳过渡，和护理人员报告说缺乏具有足够专业知识的普通全科医生来护理双重残疾的人。儿科医生和全科医生之间的共享护理流程由专门的过渡经理开发和启动，他协助护理协调和服务联系。还引入了标准化的临床评估工具，以确定患者和护理人员的支持需求。解释 本研究强调了通过早期过渡计划、评估患者和护理人员需求的一致方法以及共享护理来改善双重残疾青少年及其护理人员过渡结果的潜力。儿科医生和全科医生之间的共享护理流程由专门的过渡经理开发和启动，他协助护理协调和服务联系。还引入了标准化的临床评估工具，以确定患者和护理人员的支持需求。解释 本研究强调了通过早期过渡计划、评估患者和护理人员需求的一致方法以及共享护理来改善双重残疾青少年及其护理人员过渡结果的潜力。儿科医生和全科医生之间的共享护理流程由专门的过渡经理开发和启动，他协助护理协调和服务联系。还引入了标准化的临床评估工具，以确定患者和护理人员的支持需求。解释 本研究强调了通过早期过渡计划、评估患者和护理人员需求的一致方法以及共享护理来改善双重残疾青少年及其护理人员过渡结果的潜力。