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Outgrowing Pediatrics

How pediatric medical homes are helping young adults make smooth transitions to adult care

May 17, 2013
By Julie Eisen

In a pediatric practice, when it comes time for a patient to move on to an adult provider, there are two options: transferring or transitioning.

“Transferring a patient to adult medicine is like dropping off an 18-year-old who has never flown in an airplane at the airport and telling him to go to gate 4 in terminal C via a bus, and once he gets to his connecting flight to take the underground bus—maybe it’s red, maybe it’s blue—to terminal 413 and gate 578,” says Sally Faggella, RN, a nurse at Harvard Vanguard Medical Associates in Chelmsford, Mass. “It’s overwhelming and his chances of missing the flight are high. Transitioning is the process of giving the young adult the opportunity to walk through this journey in a supportive environment that allows him to test his skills before he has to do it independently.”

At the age of 12, a patient at Harvard Vanguard begins transitioning to adult care. It will be 6 to 10 years before the patient graduates to their next provider, but before that happens, the pediatric practice wants to ensure that their patients learn how to schedule appointments, understand their medical histories and have the skills to advocate for their own health.

Harvard Vanguard is one of 13 pediatric practices in the CHIPRA Massachusetts Medical Home Initiative. Since 2011, these health centers have been making practice-level policy changes to become patient-centered medical homes by the start of 2014. Increasingly, the medical home has become a highly regarded model of care for its focus on putting the patient and family first and providing continuity from childhood through adolescence. Grounded in delivering compassionate, coordinated care, the medical home model encourages the care team to create tailored transitioning plans for their young adult patients to gradually prepare them and their families for medical independence.


Creating a Transitioning Policy

Here are some key steps to creating a transitioning policy:

• Collaborate with providers, support staff and parents to develop a gradual transition plan policy.
• Present the proposed policy to staff as a work in progress.
• Test the policy.
• Collect feedback, refine the process and continue testing.
• Develop written documents for patients and parents outlining the policy.
• Advise staff to communicate early and openly with patients and parents about transitioning.
• Remember to be mindful of patient differences and advise staff to tailor transitioning plans accordingly.
• Remain open to feedback and additional change as patients and staff acclimate to the new standard.

Ages 11-17: Fostering Independence

While the kickoff age of the transition process varies from practice to practice, generally it falls somewhere between 12 and 14. The planning typically starts with an open conversation between the provider, the patient and the family. To help facilitate this conversation, Yogman Pediatrics in Cambridge, Mass., and Holyoke Pediatrics in Holyoke, Mass., give letters to patients and families at the time of their first transitioning visit to help them understand the practices’ policies. The parent or guardian is asked to step out of the room for part of the visit to give the young adult an opportunity to speak with the provider in private and get comfortable with one-on-one interaction. This then becomes a standard part of well visits moving forward.

“Things like getting the young adult to feel comfortable checking in, presenting their insurance and paying for the copay are important,” says Claudia Scott, a medical assistant at Harvard Vanguard. “Even if the parent gives them the money, they are actually doing the transaction.”

Yogman Pediatrics recently created materials with similar recommendations, also encouraging young adults to schedule their own visits and prepare questions for their provider ahead of time in order to develop self-advocacy skills.

Technology policies governing patient web portals can also play a role in empowering young adults to take control of their health. Some practices recently lifted their parents-only restriction and granted portal access to their patients starting at age 13, which has proven successful with a generation that is wired in.

Faggella recalls a recent example of a 13-year-old patient who recently started her period and was concerned about irregularity. Using the portal, she submitted a long question to her primary care provider and was able to have a full electronic exchange with Faggella about her concerns.

“This is how this generation communicates with people. They are able to articulate and feel much more comfortable putting things in writing,” says Faggella. “As transition moves along, we find new ways to outreach to our patients and give teens increasing responsibility for their healthcare. This will only help them when they leave home or when they start talking to us independently.”

Transitioning the Parents

As the medical home team transitions the patient toward independence and adult care, they are also transitioning the families. Families need to understand how best to help with the transition, not be a barrier.

To get parents comfortable with their role in the process, Faggella takes the opportunity to meet informally with parents in the waiting room. “We ask them, what would happen if your child was now responsible for knowing their allergies? What would you think about their being able to have access to their medical records so they can ask us questions?’” Faggella reports many parents are receptive to the transitioning process.

One transitioning milestone is when a child turns 18. Unless the patient signs a release, the practice can no longer share a patient’s health information with anyone, which can cause discomfort.

“We are a real family practice at Yogman Pediatrics. Our doctors have known our parents forever,” explains Sheila Donoyan, officer manager at Yogman Pediatrics and team leader. “This can be really hard for the parents because they are used to being a part of the family, and they still are, but legally when their child turns 18 they are excluded.”


How Do You Implement a Transition Policy?

Harvard Vanguard Medical Associates in Chelmsford, Mass., has the following independence benchmarks for transitioning its young patients to adult care.

At age 11: Patients meet privately with provider for part of visit.
Age 12: Patients should be able to identify their allergies and begin carrying a laminated copy of their insurance card.
Ages 13-14: Patients should be able to list their medications and they gain confidential access to part of their online patient portal.
Ages 15 -16: Patients should be able to provide a full list of their conditions, such as asthma.
Age 17: Patients should know and be able to discuss their family history.
Age 18: Patient becomes medically independent.
Ages 18-22: Patient fully transitions to adult care.

To prepare parents for this transition, the practices emphasize that advanced communication is key. “If you start the conversation when the child turns 18 and say ‘sorry, I can’t give you these test results without your child’s permission,’ the conversation doesn’t go well,” says Faggella. “But if you have a discussion with a 14-year-old’s parent about how transition is a gradual process with changes that will happen at age 18, the parent will be much more receptive.”

Ages 18-22: Preparing the Adult Providers

Pediatric medical homes take an active role in helping their patients move up to adult care. Not only does the process focus on the young adult’s transition, it also involves making it easy for the new adult provider.

“Not a lot of physicians out there are comfortable taking on a new patient unless there is really good communication with the pediatrician’s office and a care plan that’s very well coordinated,” says Michele Giarusso, administrator at Holyoke Pediatrics and team leader for their practice.

When first starting their work on transitioning Faggella sat down with the chief of internal medicine at Harvard Vanguard and explained that the pediatrics team would write up concise patient summaries, hand over care plans, and schedule the first appointments a year an advance. The chief was ecstatic and made five providers available to new young patients.

Giarusso echoes the need for pediatric practices to play an active role in enabling the young adult to find a new provider, especially when the patient has chronic conditions.

Young adults often don’t make preventative care well visits a high priority and may not find a provider until they run into a health crisis, notes Donoyan. “That’s what we are trying to prevent. We want to start early and give our patients medical continuity well into adulthood.”

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