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The population of interest within this paper is children and young people (aged around 10–20 years) who are afflicted by a chronic condition requiring life-long specialized care. The broad range of medical and psychosocial conditions with a congenital and/or chronic nature is in fact in the scope of this paper, ranging from somatic to psychological and neurodevelopmental conditions. This group of conditions can be defined as “any medical condition that can be reasonably expected to last (unless death intervenes) and to involve either several different organ systems or one organ system severely enough to require specialty pediatric care and probably some period of hospitalization in a tertiary care center” [9].

Transition refers to the process followed by young persons with chronic conditions in order to take charge of their health and lives in adulthood [10]. This process entails interventions, such as providing structured and repetitive patient education, counseling services of patients regarding lifestyle issues and health behaviors, and care and skill demonstration provided by transition coordinators (e.g., self-management, participation in care, self-efficacy, communication, decision-making) [10–13].

Transfer is, in general, a single occasion event through which the young patient is transferred from pediatric to adult care services. Examples of transfer-related interventions are the following: writing a transfer letter, developing a transfer plan, writing a health summary and coordinated transfer of care [9].