Health Care Transition for Adolescents with Special Health Care Needs: A Report on the Development and Use of a Clinical Transition Service

摘要

Background: A growing population of adolescents withspecial healthcare needs is aging into adulthood. Theseemerging adults face the transition challenges of theirhealthy peers but also potentially heightened risks andchallenges related to their conditions. We describe theprocess of developing a pilot program to support healthcareservices for emerging adults with chronic conditionsand present preliminary data on utilization.Results: An outpatient multidisciplinary consult modelwas developed based on patient, family and physicianfeedback. Patients with diverse conditions were equallyreferred from primary care, subspecialists and familiesand community agencies. Services provided includedneeds assessments (100%), referral to adult physicians(77%), care coordination (52%) and referrals to adultcommunity services (10%). Clinical billing did not fullysupport the cost of providing services.Conclusion: The pilot program offered multidisciplinarytransition services that were utilized by a diverse patientpopulation. Local and national resources for health caretransition are provided.