Transition From Pediatric to Adult Medical Care
The Pennsylvania Medical Home Initiative (PA MHI) efforts around transition is a natural extension of the larger program funded by the Pennsylvania Department of Health. Since 2010, PA MHI has focused on helping pediatric and adult primary care providers develop and implement processes and tools in their practices to make it easier for Youth with Special Health Care Needs (YSHCN) and their families make the leap from pediatric primary care to adult-based primary care.
Pediatric practices that have implemented the Medical Home principles and model of care through PA-MHI are invited to participate in the Transition aspect of the program. To date, there are fifteen pediatric practices and 43 adult practice that are involved in the transition quality improvement efforts.
The PA MHI transition work helps the pediatric practices identify youth between the ages of 14 and 20+ who have special health care needs and are in an appropriate place to start the process of transitioning to an adult-based primary care provider. These patients are identified in the practice electronic health record as transition-eligible so that the practice can follow their progress and make sure that the topic of transition is addressed at visits and certain tools, like the transition checklist, are given to them in a timely manner.
Adult-based primary care providers (Family Medicine and Internal Medicine) who are able to accept YSHCN are identified as partners for the pediatric practices. These practices work hand-in-hand with the pediatric practice to pave the way for a smooth transition for the patient and their family by communicating with the patient's pediatrician before the visit occurs. Patients on Medicaid can also use the PA DHS Operations Memorandum (OPs Memo) to see a potential adult-based provider before switching their designated primary care provider (PCP).
The PA Medical Home Initiative parent advisors serve as advocates and resources for the families of the transitioning youth. As parents of YSHCN themselves, these team members are in a position to help families prepare for and talk about the upcoming transition experience for their youth.
OPs Memo
What is the OPs Memo?
The OPs Memo (Operations Memorandum) is an additional contractual requirement/clarification to the PA Medicaid (HealthChoices) Program. This requirement became effective in 2009 and is monitored by the Pennsylvania Department of Human Services (PA DHS), Office of Medical Assistance Programs, (OMAP). It was written to address the issues that youth with special health care needs (YSHCN) may encounter when transitioning from pediatric to adult health care.
Who benefits from the OPs Memo?
Everyone benefits from planned transitioning for youth.
Parents
For parents of YSHCN, finding an appropriate adult doctor for their child can be a daunting challenge. Oftentimes, parents cannot afford to "try out" different adult doctors for their child because insurance won't cover the cost.
The goal of the OPs Memo is to ease the stress of transition by mandating that all Medicaid providers allow a child with special needs to meet with an adult provider while still seeing their pediatrician.
Youth
The OPs Memo makes it easier for youth to stay connected to their pediatrician until they find the adult provider who can best accommodate their special need(s).
Medical Professionals
Under the OPs Memo, pediatricians have a better understanding of their patient's future health care treatment and are more involved in the transition process.
Treating YSHCN for the first time doesn't have to be a "make or break" moment for adult providers. The OPs Memo allows for multiple visits before a final decision about the youth's health care has to be made.
Fostering overlapping visits allows youth, families and providers to discuss and coordinate the member's care from a pediatric to an adult provider. A transition plan can be developed and issues, such as what aspects of the members care should be transitioned and when the transition should take place, can be thoughtfully discussed. Optimally, this overlapping time with pediatric and adult primary care providers will improve the quality of patient and family centered care.
Who should utilize the OPs memo?
Youth who are (a) Still seeing a pediatrician when they are 18 years or older; (b) Covered under PA Managed Medicaid insurance; (c) Identified as "medically fragile" by their Medicaid provider.
FYI: A youth doesn't need to be technology-dependent or have a severe physical disability to qualify as "medically fragile" – the OPs memo defines "medically fragile" as any youth who has or is at risk for a chronic physical, developmental, or behavioral condition, and who requires more medical support than a generally-healthy child might.
Who do I contact if I have questions?
For questions on how to best use this option, please contact the Special Needs Unit of the HealthChoices PH-MCO providing the member's physical health care. The numbers of the Special Needs Units are listed below.
In Addition:
A video demonstrating use of the OPs Memo has been produced by PEAL and can be found here.
HealthChoices Special Needs Units:
Aetna Better Health: 1-866-638-1232
AmeriHealth Caritas: 1-800-684-5503
AmeriHealth Northeast: 1-888-498-0766
Coventry Cares: 1-866-427-9721
Gateway Health Plan: 1-800-642-3550
Geisinger Health Plan Family: 1-855-214-8100
Health Partners: 1-866-500-4571
Keystone First Health Plan: 1-800-521-6860
United Health Care Community Plan: 1-877-844-8844
UPMC for You: 1-866-463-1462
(University of Pittsburgh Medical Center Health Plan)