Health Care Transition for Children with Medical Complexity: Challenges and Lessons Learned

Area of Science:

• Pediatric to Adult Healthcare Transition
• Complex Care Management
• Quality Improvement in Healthcare

Background:

• The transition from pediatric to adult healthcare is critical for young adults with complex medical needs.
• Current systematic approaches and guidance for this transition are lacking for patients and families.
• Children with Medical Complexity (CMC) require structured support during this pivotal phase.

Purpose of the Study:

• To evaluate and improve healthcare transition practices for Children with Medical Complexity (CMC).
• To standardize transition guidance, planning, and documentation within a Complex Care Program (CCP).

Main Methods:

• Quality improvement efforts were initiated between 2019 and 2020.
• Practices were evaluated by healthcare providers and nurse case managers in the CCP.
• Standardization of transition guidance, planning, and documentation was the focus.

Main Results:

• Identified challenges include varied provider approaches, EMR documentation issues, and connecting to adult systems.
• Key themes for effective transition include prioritizing primary care provider transition, early conversations, unified documentation, and family involvement.
• Lessons learned emphasize the importance of a systematic approach.

Conclusions:

• Effective transition of care for CMC necessitates early, proactive conversations involving all stakeholders.
• Engaging primary and specialty providers, patients, and families is crucial for developing safe transition plans.
• Standardized processes improve outcomes for young adults with complex medical needs moving to adult care.