Multidisciplinary Support for Healthcare Transitioning Across an Urban Healthcare Network

Discussing Future Goals and Legal Aspects of Health Care: Essential Steps in Transitioning Youth to Adult-Oriented Care

“…Eleven Essential Steps of Health Care Transitioning. 14,15 Identify core knowledge and skills Have a designated pediatrician/or member of the practice who coordinates transition Identify an adult medical provider Create a portable medical summary Create an emergency plan Create a transition plan Assist with ongoing insurance coverage Discuss the legal aspects of transition Discuss realistic future goals with the adolescent alone Discuss realistic future goals with the adolescent and family Provide ongoing routine adolescent health care differed by provider and setting characteristics (described in Table 2). For each survey, within group paired comparisons of provider behaviors with regard to youth with and without SHCNs were made using McNemar tests.…”

“…• • Discuss realistic future goals with the adolescent alone • • Discuss realistic future goals with the adolescent and family • • Discuss legal aspects of health care transition Survey development and the results of both datasets have been described previously. 14,15 The surveys were voluntary and included a consent statement; all questions were optional. Both surveys were administered via SurveyMonkey and copies of the survey instruments are available on request.…”

“…14 In 2013, an adapted version of the survey was distributed to 376 pediatric providers (279 generalists, which included primary care, family medicine, and school health providers, and 97 subspecialists) affiliated with a single-institution, a large urban academic health care network, which serves approximately 36 000 youth aged 12 to 21 years in its outpatient practices each year. 15…”

“…Low rates of compliance with these specific steps were reported in 2 prior studies of pediatric providers assisting in HCT for youth with SHCNS, across New York State, 14 and across a single institution, a large urban academic health care network. 15 The goal of the current secondary analysis was to assess provider practices specific to whether providers discuss future goals with adolescents alone; discuss goals with the adolescent and their family; and whether they discuss legal aspects of HCT. In addition, we examined whether there were differences in provider practices across these 2 samples when meeting with youth with and without SHCNs, and whether characteristics of providers and settings differed among those who do and do not discuss future goals and legal aspects of transition.…”

Transition Navigator Intervention improves transition readiness to adult care and addresses barriers for youth with Sickle Cell Disease

“…However, across subspecialties and healthcare networks, few pediatric practices follow these recommendations consistently. 27,28 The role of a navigator or care coordinator who assists those with complex health conditions and healthcare needs has been demonstrated. [29][30][31][32] A retrospective report on the use of a transition navigator (TN) for patients with SCD at a single institution in Canada reported increased self-reported medication adherence and decreased loss to follow up as compared to a cohort assessed prior to implementation of the program.…”