Authors: Patience White, MD, MA and Peggy McManus, MHS
Who needs transition services to adult heath care provider?
What do providers offer/want in order to provide quality transition services?
Clinical Recommendations on Transition.
The clinical report includes an algorithm (see attached) that provides a logical framework for transition support during adolescence and young adulthood for all youth as well as a special section for YSHCN The algorithm starts with introducing a practice-wide transition policy at the 12-to 13-year-old visit, which accumulating data suggest is an important developmental time to introduce the transition process,(8, 9) and the algorithm concludes when the youth is receiving health care utilizing an adult approach to care or in an adult- health care delivery system.
A core concept of the transition process is having the youth understand and experience an adult approach to care at the age of majority or 18 years of age, even if they have not transferred to a new adult practice setting. The experience of an adult approach to care in the pediatric setting gives youth the opportunity to develop and test their skills at managing their own health care under the guidance of their pediatric provider. These self-care management skills are required to navigate the adult health care system and should be learned in the transition preparation process in the pediatric health care system. The adult approach of care acknowledges that youth, 18 years of age and older, have primary responsibility for their own health care. This represents a major shift from a pediatric model of care, in which the parent/caregiver is in charge. Youth may authorize other individuals to be involved in their health care after the age of 18 based on HIPPA privacy rules. Youth without cognitive challenges should be seen alone without their parents unless they have authorized them in writing to be present. Those with cognitive challenges may need a level of decision-making support, possibly including guardianship that formally clarifies their responsibility to manage their own health care. This should be discussed before age 18 years and the appropriate legal processes completed, if necessary. This legal information should be a part of the youth’s medical record at age 18 and sent to the new adult health care provider before the initial visit if the young adult is 18 years of age or older.
National Transition Resources. The federally funded National Health Care Transition Center, Got Transition?, developed a change package and toolkit called the Six Core Elements of Health Care Transition, based on the joint transition clinical report. The six core elements are designed for both adult and pediatric providers. The core elements include:
- Development of a transition policy that includes a young adult privacy and consent policy
- Creation of a registry to track youth/young adult’s progress
- Transition preparation for adult approach to care with readiness assessments for youth/young adults
- Transition planning for first visit with new provider by gathering the appropriate information, including health care transition plan, onepage medical summary, emergency care plan, and condition fact sheet
- Transfer of care with explicit communication and timing of transfer for the transitioning youth with the prior pediatric provider
- Completion of the transition process when the young adult is ready to fully participate in the management of their own health care
In addition, The National Health Care Transition Center developed a self-assessment tool for pediatric and adult practices that corresponds to the Six Core Elements. It allows practices to measure progress toward better transition support in primary care practice settings. The HCT Index was modeled after the Center for Medical Home Improvement’s MedicalHome Index. With this tool, each practice can assess the quality of its health care transition support as youth and young adults move through the process.
Over the past three years, the National Health Care Transition Center has worked with multidisciplinary teams including physicians nurses, social workers, youth and families from pediatrics, adolescent medicine, family medicine and internal medicine to implement a quality improvement process using the six core elements and to monitor their progress using the Health Care Transition indices. In the next issue of this newsletter, practical examples and tools will be provided for implementing each of the core elements drawing on the experiences of physicians and their team participating in health care transition learning collaborative.
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