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.


Medical Practices in our PA MHI Network


Pediatric Practices


Pediatric practices in the transition program are focused on assisting YSHCN and their families to get ready for "graduation" out of pediatrics and into adult-based primary care. The care coordinators and other team members at the pediatric medical home will talk with the youth and their family beginning at age 14 to ascertain what concerns they have as they approach the age of 18-21 with regard to planning for ongoing medical services.

Additionally, in collaboration with the practice, the family will assess strengths and areas for growth for the youth as he/she moves closer towards this graduation. Care coordinators will work with the family to develop a transition care plan and connect with any resources the youth and their family may need to support their graduation on to a more adult oriented system of medical care. The purpose of this planning and preparation is to create a smoother path to this adult oriented system so needed supports and services are not disrupted.

The PA Medical Home Team works closely with each of these practices to implement tools to assist in readiness assessment, identify good quality resources for the practices and their families, meet face to face regularly to review progress of the transition team at each practice and identify and recruit primary care practices who serve adults with whom to partner to welcome and receive graduating YSCHN.

Adult Practices


Adult practices partner with pediatric practices to provide necessary medical care and support needed for youth with special healthcare needs during the transition from pediatric care to adult care. The adult provider's transition team works closely with the pediatric transition team to ensure that all essential medical and social aspects of the transitioning young adult are effectively communicated to the new provider of care.

This process is accomplished through discussion between the pediatric and adult providers and review of relevant medical information and care plans prior to the patient's initial meeting with the adult provider of care. The adult provider then meets with the new patient to explain the young adult model of care, assess the needs of the patient, and clarify the adult provider's role in the care of the patient. As the young adult patient is integrated into the adult model of care, the new provider maintains communication with the pediatric practice for any necessary consultation.

In collaboration with our partners, the PA Medical Home Initiative helps identify adult practices that are willing and able to care for young adults with special healthcare needs and introduces them to the established system of transition. PA MHI then coordinates a partnership with nearby participating pediatric practices. The transition process is facilitated by encouraging regular communication between the adult and pediatric practices and providing regular in-person education, tools to facilitate the transition, and community resources for the practices and their families.

Youth and Family Role in Transition


From our Parent Advisors:

Transition doesn't need to be a dreaded point in time. It is inevitable, so be positive and tackle it as a family. Involvement from the youth and family is essential to a successful transition. Given the proper tools, the youth (if able) will learn how to navigate the adult healthcare system independently, while others may need some assistance or require their parents to continue to advocate and supervise their healthcare. Whatever your situation may be, thoughtful planning is key to your youth assuming the adult role of managing his or her own health.

The adult world of medical care and social services is quite different than the pediatric/adolescent world of healthcare. Youth and families should ask questions, seek advice, and research what lies ahead. Take advantage of various readiness tools, info sessions, and webinars regarding transition. When visiting the pediatrician, ask if he or she can refer you to an adult practitioner. Inquire at your (the parent's) doctor's office about their ability to provide healthcare to your youth.

If the youth has an IEP (individualized education plan), make sure to bring a list of questions or concerns about transition to the IEP meeting (transition must be addressed at IEPs beginning at age fourteen). Think of the possibilities that lie ahead after graduation, whether it is college, vocational school, work (with or without a job coach), or day programs. Will transportation be an issue? Will funding be needed? The transition coordinator at your youth's school should be able to direct you to specific programs relative to your individual situation. Utilize all supports available to you and your family. Remember, transition is just a new path on the road! Don't forget to use our website for links and resources.


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)


Transition Partners

 

The team at the PA Medical Home Initiative has partners who help us gain and maintain important information to support our work with transitioning families. Below are some of these dynamic partners:

 

national-center-for-cultural-competence
The National Center for Cultural Competence (NCCC) provides instruction to our PA Medical Home and Transition Teams on cultural and linguistic competency as well as timely resources and tools to enable the delivery of culturally competent care.
pennsylvania-secondary-transition-guide
The Pennsylvania Secondary Transition Guide is a website sponsored by the Pennsylvania Department of Education, Bureau of Special Education on behalf of the Pennsylvania Community on Transition. The website provides youth, young adults, parents, and professionals with secondary transition resources to facilitate a young person’s progress towards post-secondary goals related to education, employment, and community living.
got-transition
Got Transition is the National Center for health care transition. Working with this national organization provides our project and our teams with tools that have already been validated to assist YSCHN and their families to prepare for transition as well as an organizational assessment tool practices use to measure the current status of transition activities in their practice and measure improvements over time.
peal-center
The Parent Education and Advocacy Leadership (PEAL) Center is the family to family organization for the state of Pennsylvania. They work closely with families in the state and assist our project by disseminating critical information about health care transition through inserts in their newsletters and videos.