Standardizing Best Practices in the Transition from Pediatric to Adult Care

By Carrie Cuomo, CPNP

As pediatric healthcare providers, we often hear stories about teens and young adults who have “aged out” of our care struggling to find an adult-care provider or who face lengthy waits to get an appointment with one. Once they clear those hurdles, they also face the daunting task of bringing their new providers up to speed on all the relevant details of their medical history. It’s the first time many of these young patients have had to do anything like that.

At Cleveland Clinic Children’s, my colleagues and I have created a program called “On My Way” to help smooth the transition to adult care for both patients and their caregivers. I am presenting the highlights of the program this week during the daylong Nursing Symposium at Cleveland Clinic Children’s Pediatric Innovation Summit at the Global Center for Health Innovation in downtown Cleveland.

All about communication

Creating a more fluid process for transitioning adolescents and young adults to adult-care providers comes down to improving communication in both directions. It sounds simple, but we all know that change is hard. Our vision is to use communication to essentially “package” a patient in a carefully wrapped box of relevant information for the new adult-care provider to open in his or her office. The goal is to tend to even the smallest of pertinent details the way one would tie a bow on the box as a finishing touch.

Roots in the ‘Got Transition’ initiative

As we began researching how to begin a program, “Got Transition” rose to the top of the resources available. The Got Transition/Center for Health Care Transition is a cooperative agreement between the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health to improve the transition to adult healthcare. It has many tools and documents available to help accomplish this, and we are aiming to springboard from it to develop a process that works at Cleveland Clinic.

We hope to begin a pilot study of On My Way at two Cleveland Clinic family health centers this summer, and we expect the pilot to last six to 12 months.

On My Way at a glance

Since there is no single “right” age for transition for everyone, On My Way asks all pediatric caregivers to give their patients annual readiness surveys starting at about age 16. The surveys are to be administered annually at well visits until the results show the patient is ready to transition to adult care.

Once a patient is ready, the pediatric provider completes a medical summary sheet that reviews important past and current problems, what medications the patient is taking and other related information. This allows the adult-care provider to access all relevant information in one place rather than sifting through pages of old notes.

Providing this ready-to-go background allows the patient and his or her new provider to start establishing trust and building a relationship much sooner.

Not just for those with complex conditions

Although the word “transition” makes many in the healthcare community think of patients with chronic or complex conditions, the reality is that even so-called normal adolescents and young adults typically need help with this. Plus, there is no such a thing as a “normal” person: Every patient is treated for various problems in his or her pediatric years, and learning all of that from scratch can be difficult for the new provider.

Six elements of transition

The Got Transition initiative identified six elements of transition, and we are going to try to work through all six:

• Transition policy
• Tracking and monitoring
• Readiness
• Planning
• Transfer of care
• Transfer completion

We expect the hardest part will be engaging providers to fully participate. Fortunately, we have clinicians and leaders on both sides — pediatric and adult medicine — who have agreed to be part of the soon-to-launch pilot. They recognize the need to improve transition care and are excited to be part of the solution.

The road ahead

Our goal is for this On My Way transition tool to become part of standard practice for all Cleveland Clinic pediatric, family practice and internal medicine providers — as well as relevant specialists — in the not-too-distant future.

Ms. Cuomo is a nurse practitioner in Cleveland Clinic’s Department of Pediatric Hospital Medicine.