A hospital-wide initiative to support medically complex adolescents and young adults transition experience: The process of a systems approach to transition in a tertiary care setting

Michelle Forcier*, Sarah Ahlm, Rebecca Boudos, Parag K Shah, Shubhra Sue Mukherjee, Kathy Zebracki, Jill A Weissberg Benchell

*Corresponding author for this work

Research output: Chapter in Book/Report/Conference proceedingChapter

Abstract

Children with complex medical conditions who previously did not survive into puberty and their adult years now face the unique challenge and interactions of chronic disease management and the developmental demands of adolescence. Pediatric centers and subspecialty pediatricians that typically care for these youth with special health care needs (YSHCN) are more traditionally oriented towards younger populations and are additionally adapting to this shift in both demographics and disease management. This chapter overviews a hospital-wide approach to improve services for medically complex adolescent and young adult patients. This urban tertiary care hospital began a multispecialty, multi-disciplinary intervention to improve two important elements of transition care: improved adolescent focused health services and preparation of youth for the eventual transfer to adult health care systems. This hospital-wide endeavor included: a centralized Transition Team; institutional funding to support pilot projects; and a multidisciplinary Transition Steering Committee. Teams from liver and kidney transplant, epilepsy, oncology, spina bifida, cardiology, diabetes, infectious disease, and rheumatology participated in the program. Pilot projects developed needs assessments; screening for risk and wellness; educational modules; and partnerships with adult providers. This chapter will describe one systems-based approach to transition.

Original languageEnglish (US)
Title of host publicationTransition from pediatric to adult medical care
PublisherNova Science Publishers, Inc.
Pages85-100
Number of pages16
ISBN (Electronic)9781620814123
ISBN (Print)9781620814093
StatePublished - Jan 1 2012

ASJC Scopus subject areas

  • Health Professions(all)
  • Medicine(all)

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