Pilot Program Helps Pediatric Patients Transition to Adult Care

Approximately 18 million U.S. adolescents ranging from 18 to 21 years old are nearing adulthood and will need to transition from pediatric to adult-centered healthcare, according to the 2013 Current Population Survey of the U.S. Census Bureau. How are healthcare systems helping patients transition smoothly? That’s a question that piqued the interest of Carrie Cuomo, MSN, CPNP, Manager of Advanced Practice Nursing in Cleveland Clinic’s Pediatric Institute.

“Young adults have often been with the same healthcare provider all their lives, then they hit 21 years and are expected to establish a new provider quickly,” says Cuomo. “Pediatric providers can help begin a more fluid process for transitioning adolescents and young adults to adult-care providers.”

Cuomo and her colleagues in the Pediatric Institute have created a program called “OnMyWay” to facilitate that transition. It is currently being piloted at Cleveland Clinic’s Willoughby Hills Family Health Center. The program’s primary objectives are to:

• Provide an evidence-based support process for healthcare teams to follow.
• Create tools in the electronic medical record that follow six core elements of transition.
• Improve patient readiness and health knowledge prior to transfer to the new provider.

Six core elements of a transition program

Cuomo began researching how to create a transition program several years ago and discovered Got Transition, a cooperative agreement between the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health. It takes a multifaceted approach to improving the transition to adult healthcare. Cuomo and her colleagues used many of the tools offered by Got Transition as a springboard for their OnMyWay program, most notably the organization’s six core elements of a transition program.

To successfully move a pediatric patient to adult care, OnMyWay leads physicians through these steps:

1. Develop a transition policy for both pediatric and adult care providers.
2. Develop a register to track and monitor patients.
3. Assess the readiness of both the patient and their caregiver to switch providers.
4. Conduct transition planning.
5. Transfer care of the patient.
6. Complete the transition and receive feedback on the process.

Cuomo says the transition planning step is the hardest and longest part. “Providers work together on a plan of care, emergency care plan and medical summary,” she says. “At the same time, pediatricians and nurses work with patients to ensure they understand – and can communicate with healthcare providers – their medical conditions and diagnoses.” Parents typically talk to pediatricians about their child’s diabetes, allergies or attention deficit disorder. During transition planning, young adults learn how to discuss their health with providers.

“This whole process is about preparing adolescents – allowing them to take ownership of their health and giving parents permission to let their child become independent,” says Cuomo. Conversations about transition can begin as early as 12 years old, though the actual transition may not occur until the patient is 20 or 21 years old.

Pilot program shows promise

Cuomo began a pilot study of OnMyWay with pediatric and adult providers at the Willoughby Hills Family Health Center in February. Two pediatricians are participating in the program, which is offered to every 19- to 21-year-old who comes in for an appointment. To date, the pediatricians have registered 20 patients who are in the transition planning phase of the program.

“The providers have told me that introducing the program and giving patients the readiness assessment has opened up conversations they never had before,” says Cuomo. “It’s been a great tool for starting important conversations about all kinds of ‘adult’ topics for these adolescents.”

Cuomo hopes to begin a pilot program at a second family health center this fall. While convincing physicians to take part in the transition initiative has been challenging, Cuomo remains committed to OnMyWay.

“Growing up is hard, and anything we can do to make the transition easier will help ensure success for these young adults,” she says. “Teaching them how to manage and take ownership of their health is laying the groundwork for a healthy life far into the future.”