A Multidisciplinary Transition Consult Service: Patient Referral Characteristics

Area of Science:

• Pediatric healthcare
• Healthcare transition
• Interprofessional collaboration

Background:

• Children's hospitals face increasing numbers of young adults with complex needs requiring developmentally appropriate care.
• Transitioning young adults from pediatric to adult-oriented healthcare presents unique challenges.

Purpose of the Study:

• To describe the patients, services, and short-term outcomes of an interprofessional healthcare transition (HCT) consult team.
• To evaluate the effectiveness of a specialized HCT team in managing complex young adult patients.

Main Methods:

• An interprofessional team (nurses, social workers, community health worker, physicians) was formed.
• A tiered population framework stratified patients by medical complexity.
• Eligibility criteria included age (≥18 years), ≥2 specialists, or intellectual/developmental disability (IDD).
• Comprehensive medical and psychosocial assessments were conducted to prepare patients for adult care.

Main Results:

• The team received 197 referrals; patients often had multiple specialists (73%), IDD (71%), or technology dependence (37%).
• Services included navigation of mental health (39%), insurance (13%), IDD services (15%), and guardianship (37%).
• 30 medically complex patients were successfully transferred to adult care, enhancing pediatric capacity.

Conclusions:

• An interprofessional team approach effectively addresses the multifaceted needs of medically and psychosocially complex young adults transitioning to adulthood.
• This model improves pediatric healthcare system capacity by managing complex cases and facilitating transitions to adult care.