Developing a Hospital-Wide Transition Program for Young Adults With Medical Complexity

Area of Science:

• Healthcare transition management
• Pediatric to adult care coordination
• Complex care models

Background:

• Transitional age adults (18-24 years) represent a rapidly growing patient demographic in pediatric hospitals.
• Standardizing the transfer of care for complex adult patients from pediatric to adult healthcare systems is a critical challenge.

Purpose of the Study:

• To standardize pediatric to adult healthcare transfers for complex adult patients.
• To implement a tiered and multimodal population-based intervention to improve transition processes.

Main Methods:

• Development of the Multidisciplinary Intervention Navigation Team (MINT) to reduce transition variations.
• System-level goals included increasing provider engagement, transition tools, EMR decision support, policies, education, and referral networks.
• Implementation of an adult transition consult service (MINT Consult) for complex cases.

Main Results:

• MINT increased transition policies and EMR tool utilization across seven divisions.
• Seven psychoeducational events were held, and a clinical pathway was developed.
• Over 70 patient referrals were received, with a median age of 21; 70% had intellectual disabilities. Referring providers reported MINT facilitated adult provider identification and care coordination, saving significant time.

Conclusions:

• MINT enhanced the availability, knowledge, and use of transition resources.
• The intervention led to significant time savings for care team members.
• Provider comfort and confidence in managing transition-related conversations were notably increased.