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At some point, pediatric patients transition to an adult medical home (or in family medicine practices to an adult care model). Although potentially challenging for any patient, transition to an adult care system might be especially complex for patients with special healthcare needs. To maximize the probability that these transitions will be orderly and responsive to the needs of patients, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians updated a 2002 consensus statement to “advance the practice-based implementation of planning, decision-making, and documentation processes for youth who are approaching transition.” Highlights of the clinical report include the following:
For patients aged 12 to 13 years, begin discussions with parents and youth about office transition policies (expected age of transfer; patient, family/caregiver; and medical home responsibilities in the transition process), and provide the transfer policy in writing. Review each patient's medical record to identify any special healthcare needs.
For patients aged 14 to 15 years, develop a written transition plan with patients and their parents or guardians.
For patients aged 16 to 17 years, review and update the transition plan to reflect changes in the patient's medical status and patient or parent concerns, and prepare the patient for adult care. A “pretransfer” visit to the adult medical home might be worthwhile.
For patients aged 18 years or older (depending on the patient's developmental level), the patient should be transferred to adult care; in family medicine practices, an adult medical care model should be initiated at this point.
For youth with special healthcare needs, transition planning can be facilitated by developing a registry of patients in the practice with special needs; continuously update written care plans (including advance directives and details about the youth's developmental level and readiness to assume responsibility for self-care) and care coordination plans (including information about the specific comanagement responsibilities of the primary care physician and each subspecialist).
Identify the adult medical home (and subspecialists) that will accept the patient, and provide the full range of care and coordination needed.
The authors call for adequate reimbursement for transition care planning and for adequate insurance for youth throughout the transition process and into young adulthood.
American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Transitions Clinical Report Authoring Group. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics 2011 Jul; 128:182.
Comment
This report (complete with useful algorithms) emphasizes that unless practices take these specific steps, transition to adult care risks being haphazard. Implementing these policies will serve all our patients but will be particularly beneficial to youth with special healthcare needs and the providers who assume their care. The report suggests that transition planning begin at age 12 years and occur at age 18, but clearly the timing at either end of the process must be individualized based on the adolescent's developmental level, the complexity of his or her chronic condition or conditions, the readiness of the adolescent and family to begin the planning process or to change providers, the characteristics of the current medical home, and the ability to identify a suitable adult medical home.