Transition of Care to Adult Services
Improved medical care and increasing numbers of adults with childhood-onset disabilities has lead to much interest and concern about the transitioning of care of young adults from a family-centered pediatric approach to a self-directed adult care model (2).
Pediatricians often will maintain care for their patients well into adulthood, especially for those with complex medical conditions (264). A consensus policy statement, adopted by the American Academy of Pediatrics, American Academy of Family Physicians, and the American College of Physicians—American Society of Internal Medicine, states that the transition of care should “maximize lifelong functioning and potential through the provision of high-quality, developmentally appropriate health care services that continues uninterrupted as the individual moves from adolescence to adulthood.” (265) Barriers to transitions cited include lack of adult provider training, poor communication between pediatric and adult providers, and need for self-direction navigating the adult system (266). There have also been suggestions for specific elements to support a transition, such as preparation, flexible timing, care coordination, transition clinic visits, and interested adult care providers; however, this remains theoretic (267). At present, the science is at an early stage of development (266,268). Adolescents with early-onset and chronic health care needs have received an organized level of care, and maintaining coordination of often complex care is an important part of quality health care over a lifetime.There have been reports of successful transition of service models. Successes related to planned and evaluated transitions (269), personal health records management (269,270), and provision of education on health and needs (271). There remain questions regarding shared responsibilities for the transition (272-274), need for protocols (275), and timing for planning and implementation. Pediatric physiatrists can often provide the stability for this transition. Table 15.3 identifies challenges for transitioning health care from pediatric to adult systems of care (276).
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