Transition From Pediatric to Adult Medical Care

The Pennsylvania Medical Home Initiative (PA MHI) efforts around transition is a natural extension of the larger program funded by the Pennsylvania Department of Health. Since 2010, PA MHI has focused on helping pediatric and adult primary care providers develop and implement processes and tools in their practices to make it easier for Youth with Special Health Care Needs (YSHCN) and their families make the leap from pediatric primary care to adult-based primary care.

Pediatric practices that have implemented the Medical Home principles and model of care through PA-MHI are invited to participate in the Transition aspect of the program. To date, there are fifteen pediatric practices and 43 adult practice that are involved in the transition quality improvement efforts.

The PA MHI transition work helps the pediatric practices identify youth between the ages of 14 and 20+ who have special health care needs and are in an appropriate place to start the process of transitioning to an adult-based primary care provider. These patients are identified in the practice electronic health record as transition-eligible so that the practice can follow their progress and make sure that the topic of transition is addressed at visits and certain tools, like the transition checklist, are given to them in a timely manner.

Adult-based primary care providers (Family Medicine and Internal Medicine) who are able to accept YSHCN are identified as partners for the pediatric practices. These practices work hand-in-hand with the pediatric practice to pave the way for a smooth transition for the patient and their family by communicating with the patient’s pediatrician before the visit occurs. Patients on Medicaid can also use the PA DHS Operations Memorandum (OPs Memo) to see a potential adult-based provider before switching their designated primary care provider (PCP).

The PA Medical Home Initiative parent advisors serve as advocates and resources for the families of the transitioning youth. As parents of YSHCN themselves, these team members are in a position to help families prepare for and talk about the upcoming transition experience for their youth.

Pediatric Practices

Pediatric practices in the transition program are focused on assisting YSHCN and their families to get ready for “graduation” out of pediatrics and into adult-based primary care. The care coordinators and other team members at the pediatric medical home will talk with the youth and their family beginning at age 14 to ascertain what concerns they have as they approach the age of 18-21 with regard to planning for ongoing medical services.

Additionally, in collaboration with the practice, the family will assess strengths and areas for growth for the youth as he/she moves closer towards this graduation. Care coordinators will work with the family to develop a transition care plan and connect with any resources the youth and their family may need to support their graduation on to a more adult oriented system of medical care. The purpose of this planning and preparation is to create a smoother path to this adult oriented system so needed supports and services are not disrupted.

The PA Medical Home Team works closely with each of these practices to implement tools to assist in readiness assessment, identify good quality resources for the practices and their families, meet face to face regularly to review progress of the transition team at each practice and identify and recruit primary care practices who serve adults with whom to partner to welcome and receive graduating YSCHN.

Adult Practices

Adult practices partner with pediatric practices to provide necessary medical care and support needed for youth with special healthcare needs during the transition from pediatric care to adult care. The adult provider’s transition team works closely with the pediatric transition team to ensure that all essential medical and social aspects of the transitioning young adult are effectively communicated to the new provider of care.

This process is accomplished through discussion between the pediatric and adult providers and review of relevant medical information and care plans prior to the patient’s initial meeting with the adult provider of care. The adult provider then meets with the new patient to explain the young adult model of care, assess the needs of the patient, and clarify the adult provider’s role in the care of the patient. As the young adult patient is integrated into the adult model of care, the new provider maintains communication with the pediatric practice for any necessary consultation.

In collaboration with our partners, the PA Medical Home Initiative helps identify adult practices that are willing and able to care for young adults with special healthcare needs and introduces them to the established system of transition. PA MHI then coordinates a partnership with nearby participating pediatric practices. The transition process is facilitated by encouraging regular communication between the adult and pediatric practices and providing regular in-person education, tools to facilitate the transition, and community resources for the practices and their families.

Transition Partners

The National Center for Cultural Competence (NCCC) provides instruction to our PA Medical Home and Transition Teams on cultural and linguistic competency as well as timely resources and tools to enable the delivery of culturally competent care.

The Pennsylvania Secondary Transition Guide is a website sponsored by the Pennsylvania Department of Education, Bureau of Special Education on behalf of the Pennsylvania Community on Transition. The website provides youth, young adults, parents, and professionals with secondary transition resources to facilitate a young person’s progress towards post-secondary goals related to education, employment, and community living.

Got Transition is the National Center for health care transition. Working with this national organization provides our project and our teams with tools that have already been validated to assist YSCHN and their families to prepare for transition as well as an organizational assessment tool practices use to measure the current status of transition activities in their practice and measure improvements over time.

The Parent Education and Advocacy Leadership (PEAL) Center is the family to family organization for the state of Pennsylvania. They work closely with families in the state and assist our project by disseminating critical information about health care transition through inserts in their newsletters and videos.