The American teenage population is for the most part a generally healthy one. While you may be tempted to keep visits concise, consider: are you offering your adolescent patients the tools they need to manage their adult healthcare?
When a child enters adolescence, there are many things that should be on a pediatrician’s mind. You could be considering approaching or present signs of puberty, determining that the patient gains the tools needed for appropriate mental, physical, and emotional self-care, and finally that they are successful in their growing and changing social communities. A 10, 12, or even 15-year-old is still a child, after all, and as their PCP and hopefully their medical home, your practice’s first priority is their ongoing health.
The Importance of Transitional Healthcare
But according to Dr. Jennifer Gray, MD, FAAP of Pearland Pediatrics in Pearland, Texas, this also includes their readiness to transition to a new medical home at an adult healthcare practice, with the knowledge in hand to keep themselves in good health. Gray has recently implemented transitional healthcare process for adolescents at her practice and spoke on the experience at PCC’s 2019 User’s Conference. “By making adolescent transition a priority,” she said, “We are equipping young adults for a healthier future by encouraging them to establish care with an adult primary care physician, teaching them to take ownership of any health conditions they carry, educating them on their diagnoses and medication treatments, and promoting their ability to navigate an often complex healthcare system.”
The process of transitioning youth to adult care practices is, like many other aspects of pediatric care, up to the individual provider and office. The practice could choose to refer patients to connected health care centers or hospitals, answer the parent or patient’s questions, or simply transfer medical records to their new PCP when requested.
According to the U.S. Department of Human & Health Services, “As adolescents grow into young adulthood, they become less likely to exercise or get regular physicals and dental check-ups. They also are more likely to have a poor diet and engage in risky behaviors (e.g., smoking, drinking, and drug use) that can lead to injury, illness, or death.” To introduce the knowledge and practice of consistent adult healthcare early is to introduce a track that will benefit the young adult throughout their life, and could even help to prevent the symptoms that could occur as a result from a gap of care, especially for patients with mental illness and other chronic conditions.
“I encourage practices to consider making adolescent transition a part of their teenage well visits. Adolescent transition is so much more than just finding a new PCP for the patient. It involves years of preparation so that the young adult patient develops the skills to successfully manage their own health and navigate an often complex healthcare system.” - Jennifer Gray, MD, Pearland Pediatrics
Transitioning to Transitory Care
Dr. Gray was a co-speaker at PCC’s recent User’s Conference on the importance of transitioning adolescents to adult healthcare. She spoke of the sometimes-challenging experience of adopting the resources and processes that would enable teen patients at Pearland Pediatrics to learn and participate in their own healthcare journeys. The 9-provider practice began the process of implementing adolescent transitional care guided by the studies of Delia Garcia, who began her tenure at Pearland as a FNP, is currently a Doctoral student at the University of Texas Health Science Center, and is a practicing DNP and Bioinformatician at the practice.
In cooperation with the team, Garcia designed and observed a Quality Improvement initiative as a requirement for her Doctoral degree. “Our quality improvement initiative helped us better understand that by incorporating interprofessional collaboration, technology, innovation and creativity, healthcare professionals can develop and implement a program that organizes a systematic approach to transition adolescents from a pediatric to an adult medical home," Garcia said.
Garcia’s study led her and Gray to create an Adolescent Transition Readiness Assessment, a paper form distributed to teens at each well visit from the age of 14. The form was a hard sell for the practice staff at first, Gray said, given that families already have so many to complete. She also spoke during her talk about handling protective parents who attempt to complete the form themselves. This is not ideal because the assessment contains questions only the teen can answer, such as “I know or I can find my doctor’s phone number,” and “I know my own medicines, what they are for, and when I need to take them.” To combat this issue, Pearland Pediatrics began distributing a second form for parents to complete.
The assessment includes a “Yes, I know this” or “No, I need to learn” checkbox for each question, several boxes for the patient to complete detailing what they need to learn and when to learn it by, and finally a QR code for the patient to scan with a smartphone. The QR code opens a short webpage guide on the topic the child wants to explore. An included bookmark helps to isolate the desired QR code and links to “The Road to Independence” companion book, which includes sections that expand upon the readiness assessment for well visits from 14 to 18.
Transitory care is not about wanting to hurry teen patients away from pediatric care, but an essential part of the responsibility that pediatricians have to their patients -- and an important extension of care into adulthood.
Resources for Practice-specific Transitions
While these resources were constructed with Pearland Pediatrics in mind, Gray and Garcia say that the AAP’s Got Transition website was invaluable in their research, and is filled with materials and resources easily customizable to an individual practice.
"We used the Model for Improvement framework for establishing a process to mobilize clinicians to improve the care of patients transitioning to adulthood,” Garcia said. “Our process improvement approach encompassed interventions that were aimed to help overcome known barriers in the literature that are known to halt transition planning efforts." The website is based on a partnership between the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health, and relies on six core elements of healthcare transition.
Dr. Gray reported that there were challenges introducing talk of transitions in her practice. Some patients and families were nervous that the practice was attempting to transition them at 14 or 15, but that is certainly not the case. She said other hurtles included assuaging the fears of parents who are unwilling to cede control to their children, and families who had long-standing relationships with their practice and who were unwilling to leave.
The relationship between pediatricians and their patients and families is a crucial one, but Gray does recommend having a firm “cut-off” age according to practice standards. Yet whether that age is 18, 20, or 25, she said during her talk that transitory care is not about wanting to hurry teen patients away from pediatric care, but an essential part of the responsibility that pediatricians have to their patients -- and an important extension of care into adulthood.
Says Gray, “I encourage practices to consider making adolescent transition a part of their teenage well visits. Adolescent transition is so much more than just finding a new PCP for the patient. It involves years of preparation so that the young adult patient develops the skills to successfully manage their own health and navigate an often complex healthcare system.”
She continues, “As pediatricians we make preventive care and anticipatory guidance a part of every well visit for 18 or more years, so why would we not extend this to include a process for transitioning to adult care? I believe it is an important role as pediatricians and gives us one last opportunity to impact the future for healthy adults.”
Providers know that every well visit is crammed with things to cover, but Gray recommends clinicians to consider transitional care as a process that takes place over years of well visits. By making it easy and accessible, the adolescent takes over the responsibility of guiding their own healthcare, building a relationship with their providers, and making long-term healthcare decisions. After all, says Gray, “that’s really the point.”