Viewpoint: Prepared for transition with nowhere to go

December 1, 2009

An editorial on the importance of transition of care

Long before the concept of the medical home became a national priority, pediatricians embraced the goal of providing primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. Articles in this issue and the November issue discuss the pediatrician’s responsibilities at the beginning and end of a child’s life in the medical home. In the November issue, Drs. Marcias and Lipkin elaborated on the AAP’s recent policy statement on developmental surveillance and screening during the first years of life (see www.contemporarypediatrics.com/devpt1), and in this issue, Dr. Sanders and colleagues provide guidance regarding the sometimes difficult transition from pediatrician to adult provider.

The pediatrician, as medical home “parent,” partners with the family in systematic developmental and medical assessment of infants and young children, referring when needed and coordinating recommended interventions. When this partnership works effectively, the pediatrician is trusted and depended upon by the family and the growing child. For the family of a child with special needs, whether developmental, behavioral, or medical, the pediatrician partner is particularly important-not only for advice and medical care, but also as a guide through hospitalizations, specialists, and school-related problems.

For the healthy, developmentally normal teen or young adult, transition from pediatrician to an adult provider is of little concern. In fact, many young adults defer seeking an adult provider until a particular need for medical care or documentation of a physical examination forces the issue. Inattention to this transition is hazardous, however, for the teenager with a chronic medical condition or with a developmental disability. Whatever the condition, an adult provider will be needed to address acute problems, medication needs, referrals, and counseling.

Dr. Sanders et al emphasize the importance of ensuring that teens with special needs are referred to a qualified provider, that their medical history is carefully summarized for that provider, and that the transition process begins by the time the patient is 14 years old. That guidance makes the assumption that there is a qualified, available, and interested physician to whom the adolescent can be “transitioned.” Most adult providers, however, have little to no experience with many of the medical and neurodevelopmental conditions for which we hope they will assume responsibility.

Whether an adult subspecialist is needed to care for a patient with cystic fibrosis or a generalist to coordinate the care for a young adult with developmental disabilities, a willing recipient provider may be difficult to identify. Physicians with dual training in pediatrics and internal medicine as well as nonphysician providers may help solve this problem, but without education and training, the adult provider may be reluctant and unprepared to accept the patients we send them. It’s unlikely that pending health insurance reform legislation will provide a solution unless incentives are included that encourage internists to open their medical homes to our young adult patients with special needs.

DR.MCMILLAN, editor-in-chief of Contemporary Pediatrics, is professor of pediatrics, vice chair for pediatric education, and director of the pediatric residency training program, Johns Hopkins University School of Medicine, Baltimore.