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 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.