Ellen Fremion, MD, outlines strategies to support smooth transitions from pediatric to adult care, stressing early planning and strong collaboration.
Ellen Fremion, MD: Transitioning youth with complex needs to adult care requires early planning
In an interview about her presentation at the AAP 2025 National Conference and Exhibition, Ellen Fremion, MD, associate professor of Internal Medicine and Pediatrics at Baylor College of Medicine, explained that transitioning youth from pediatric to adult-oriented care can take 1 to 2 years to ensure primary and specialty care is established. For some patients with rare conditions, pediatric specialists may remain involved in ongoing care.
Several factors determine the ideal timeline, including medical stability, pending surgeries, or unmet mental health and social needs. “Post-discharge from the hospital is a vulnerable time for everyone and not the best time to transfer to a whole new care team/health system,” Fremion said.
Insurance considerations are another critical factor, such as the need to apply for adult disability determination at age 18 or switching from pediatric to adult Medicaid plans. Hospital policy and provider licensure also affect timing, as some pediatric hospitals set strict age limits or restrict care to age 21. A transition can only proceed once an adult provider is identified, accepts the patient’s insurance, and has appointment availability.
Fremion noted that successful transitions depend on local resources and team composition. Models include adolescent or young adult clinics, nurse-led programs, specialist clinics, or co-management between pediatric and adult teams.
In her spina bifida transition and adult medical home clinic, physicians create summaries, nurses coordinate care and provide education, and social workers assist with insurance, decision support, and community resources. Fremion emphasized that physicians play a key role in developing pediatric–adult partnerships and adjusting care plans before transfer.
Fremion stressed the importance of early preparation. “From birth/diagnosis of disability, celebrate the child and create an imagination for the child and family about their future adult life,” she said.
Structured transition planning should begin at ages 12 to 14, covering topics such as self-management, insurance, and decision-making. Plans should be revisited annually and reinforced at follow-up visits. Discussions between ages 17.5 and 18 are particularly important to address insurance and legal changes at adulthood.
As highlighted in the AAP 2025 presentation, Fremion encouraged pediatricians to become familiar with local transition planning resources such as teen clinics, coordinators, and social workers. Insurance eligibility should be reviewed regularly, as rules for Medicaid vary by state. Families should also be made aware of marketplace plans, federally qualified health centers, and home- and community-based waiver services for children with disabilities.
To facilitate smooth handoffs, Fremion recommended that pediatricians build relationships with adult providers, understand their insurance participation, and ensure that providers have the capacity to manage patients with rare or complex needs.
Reference:
Fremion E. N. Transitioning Children with Disabilities into Adult Care. Presentation. Presented at: American Academy of Pediatrics 2025 National Conference & Exhibition. September 26-30, 2025. Denver, Colorado
Access practical, evidence-based guidance to support better care for our youngest patients. Join our email list for the latest clinical updates.
