Transitioning Patients from Pediatric to Adult Care

Adults ages 18 to 25 are among the highest users of emergency departments, says Carrie Cuomo, DNP, CPNP, Director of APRN/PA Services at Cleveland Clinic’s Pediatric Institute.

“They often use emergency departments for their medical care, and that’s mostly due to the fact that they are not plugged into a primary care provider,” she says. “They are not funneled through the healthcare system in a fashion that links them to relationships with new adult-care providers.”

Cuomo and Julie Corder, MSN, PCNP- BC, a pediatric nurse practitioner at Cleveland Clinic, is spearheading a pilot program to help transition pediatric patients to adult care.

“Having a care transition program addresses the triple aim of healthcare: It increases patient and provider satisfaction, improves patient outcomes and decreases cost,” says Cuomo.

System support

Cuomo has been advocating for pediatric–to-adult-care transition since 2014, when she completed a related project as a fellow in the Johnson & Johnson Nurse Innovation Fellowship Program. Corder’s interest in the topic was sparked years ago when she was caring for pediatric patients with kidney transplants. Together, the advanced practice nurses led care transition continuous improvement projects with providers at a family health center.

The care transition initiative gained enterprise-wide momentum when Kendalle Cobb, MD, a family physician at Cleveland Clinic, connected with the nurses and championed the program. The initiative is now supported by Cleveland Clinic Community Care, which offers primary care.

Cleveland Clinic’s care transition initiative uses Got Transition®, a federally funded program from The National Alliance to Advance Adolescent Health. The healthcare system relies on the program’s Six Core Elements™ as its base: transition and care policy/guide, tracking and monitoring, transition readiness, transition planning, transfer of care and transfer completion. There are implementation guides for each of the elements.

“Care transition is a process that takes years of preparation as opposed to a patient transfer, which is one and done,” says Corder. “During the transition, we help prepare patients for autonomy and independence, and we make them feel comfortable talking to providers, expressing who they are and explaining their symptoms and concerns.”

Pilot programs

The pilot programs under way include rehabilitation, asthma, adult primary care, pediatric primary care, the Beachwood Family Health and Surgery Center, spina bifida, pediatric nephrology and epilepsy. All of the groups use the same readiness assessment. From there, each pilot looks slightly different.

“They take all the tools we have built with Got Transition and tweak them based on their patient population,” says Cuomo. “The only requirement is to follow the six steps and go through the process.” Ideally, transition begins at age 12 and continues until transfer completion at age 21.

One of the pilots that has made strides is pediatric primary care, which created an order for consult to adult primary care within Cleveland Clinic’s electronic medical record system.

“If I want to transition one of my patients, I place the order and it goes to a scheduling pool within Cleveland Clinic Community Care. They contact the patient to begin the transition to an adult provider,” says Corder. The scheduler asks patients about their provider preferences, such as whether they want to see a male or female physician and whether they want to go to the main campus or a community hospital or health center. The schedulers also know which adult providers are accepting new patients and can track where pediatric patients end up.

Transition tips

Cuomo and Corder offer advice for other healthcare organizations that would like to implement a pediatric-to-adult-care transition program:

• Enlist a physician champion. “You can be passionate about this, but you really need buy-in and support from someone in upper level leadership,” says Cuomo.
• Use Got Transition resources. “You don’t have to reinvent the wheel,” says Corder. “There is a wealth of information, including how to customize resources, in the implementation guides.”
• Prepare for a long project. “Transition is not a fast process. You are not going to press a button and switch pediatric patients to a new provider,” says Cuomo. “It’s a departure from the baseline way of doing things that requires changing behaviors of patients, parents and providers.”
• Use virtual tools. “Virtual visits between patients and pediatric and adult providers provide a great way to do warm handoffs,” says Corder. “Everyone can share information, and patients and their families are reassured they are in good hands.”
• Create educational components for caregivers. Cleveland Clinic developed an online learning module for transition of care for everyone involved in the pilots, which includes physicians, nurse practitioners, clinical nurses, medical assistants and others. It helps people understand the difference between transferring and transitioning patients.
• Develop a sustainable plan. “Try to incorporate the process into the office practice and flow of the clinic visit so it’s not a disruption,” says Corder. For example, Cleveland Clinic pediatric primary care added the readiness assessment tool in with other screening tools required at certain ages, such as tuberculosis and depression screens. “We had much better assessment completion rates when it was incorporated into the traditional workflow as opposed to making it a special project or add-on,” says Corder.
• Don’t get discouraged if you stumble – “We’ve learned something each step of the way, even during the two continuous improvement projects that didn’t turn out as we planned,” says Cuomo. “So when we finally found Dr. Cobb and enlisted her as our advocate, we were ready to hit the ground running.”

So far, only a handful of patients have completed the transition process. One of the success stories is a 22-year-old patient of Corder’s with a brain abnormality that prevents him from walking or talking.

“But transition completions are not the outcome we are looking for right now because we know it’s going to be many years in the making,” says Cuomo. “The buy-in from everyone and the excitement that continues in each pilot is the best part.”