When patients rely on medical devices, such as a gastric feeding tube, tracheotomy, or wheelchair, it helps to know where the family or previous facility obtained the specific equipment in case a replacement becomes necessary. Staying on top of the patient’s insurance coverage also is vital in a transition, Dr. Hunt says.
Communication should flow easily between providers in inpatient and outpatient settings, as adolescents with chronic conditions are “aging out of the pediatric system,” says Allen Friedland, MD, program director of the combined med-peds residency at Christiana Care Health System in Newark, Del.
Soon they are “thrust into the adult world, which has an entirely different paradigm,” Dr. Friedland says. Among the challenges is linking a hospital’s electronic health records to interface with the information given to the outpatient physicians overseeing a patient’s care.
Christiana Care Health System has collaborated with Nemours/Alfred I. duPont Hospital for Children in nearby Wilmington, Del., to transition patients with complex medical conditions into adult care. Nemours is providing comprehensive summaries, which indicate the types of subspecialty care that a patient could require in the future. “We sort of take some of the mystery out,” Dr. Friedland says. “We really anticipate the issues.”
The worst mistake you can make is to put off planning for the transition. When families are in crisis, they return to what they know, so they are likely to show up in your pediatric emergency room even though their child is now 19 or 20 years old.
—Emily Chapman, MD, pediatric hospitalist, Children’s Hospitals & Clinics of Minnesota, Minneapolis
Meanwhile, Christiana Care started an outpatient primary-care practice staffed by two physicians, a social worker, and a psychologist liaison. They coordinate with a physician and social worker at Nemours. Secure email also helps facilitate discussions about transitions of care between the pediatric and adult settings.
The teams have access to the transition-care practice providers for round-the-clock consultations, and Dr. Friedland assists in admitting patients to the most appropriate level of hospitalized care. “When a person goes to the ED,” he explains, “there’s already a set of expectations and orders.”
The Choice Is Yours
When staying in the hospital, some patients feel more comfortable on a pediatric floor, others in an adult environment. That’s why Keely Dwyer-Matzky, MD, and Amy Blatt, MD, both Med-Peds hospitalists, created an educational video for adolescent patients at the University of Rochester Medical Center in New York.
“There’s a lot of fear about transitioning, not knowing what it’s going to be like, what the expectations are, or the feeling of the floor itself,” Dr. Dwyer-Matzky says. The video informs viewers about the importance of keeping medical summaries of their problems and speaking up for themselves at visits to their doctors’ offices. It also mentions that the Rochester facility gives adolescents the option to tour an adult floor.
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Increasing Survival to Adulthood
“There are a lot of variables,” says Shelley W. Collins, MD, chief of the pediatric hospitalist division at the University of Florida at Gainesville. “If their cognitive level allows them to be participants in their own care, then I think we have obligation to ask them what their preference is.”
The state law that governs where an HM group practices also factors into the equation. In an emergency, a court order could be obtained if a procedure is deemed necessary and a legal guardian has not been established or the patient will not consent, Dr. Collins says of Florida law. “But we prefer to have a patient agree to it. In fact, we like and require the assent of a teenage patient, who can give it in addition to the consent of the parents.”