Transitions between pediatric and adult healthcare models can be one of the most trying and health-destabilizing things a young person and their caregivers experience. Healthcare professionals on both the sending and receiving ends of this transition need training in how to facilitate successful transitions. Resources like medical society recommendations and GotTransition.org can help, but there are many challenges to successful transition of which healthcare teams must be aware in order to assist their patients through the process.

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Show Notes
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Learning Objectives:
  1. Define Healthcare Transitions. 
  2. Describe two barriers that patients and families face in transitioning to an adult-centered model of care.
  3. ​Describe two barriers that healthcare professionals face in comprehensive transition.
  4. Identify specific challenges that patients with complex medical needs face during the transition process.

Co-hosts’ Notice: Physician and provider are terms used interchangeably by many in the medical community. The DEI Shift podcast team endorses and supports the use of physician in place of provider where applicable as outlined in ACP policy.

[0:00-1:22] Introduction
  • ​Introduction of our co-hosts, guest, and the episode topic. ​

​[1:22-2:31] Introducing Guest Dr. Shirin Alonzo
  • Dr. Shirin Alonzo
    • Meds/Peds primary care physician with a neurodevelopmental specialty 
      • Focus on special needs and complex care pediatric conditions
    • Masters of public health with focus on family and community health 

[2:31-5:01] “A Step in Your Shoes” Segment

[5:01-11:05] Transitions of Care Definitions
  • Transitions of care from the pediatric to the adult health care system
    • Defined by the Society of Adolescent Medicine as the purposeful, planned movement from a child to adult oriented healthcare system to provide  uninterrupted, coordinated, developmentally appropriate, psychologically sound and comprehensive healthcare
  • Challenges in consistency and clarity about defining patients who are medically fragile
    • Defined by the Federal Maternal and Child Health Bureau as children at increased risk for or have a chronic physical, developmental, behavioral, or emotional condition
    • Defined medically as non-ambulatory patients with conditions that warrant 24 hour nursing care

[11:05-20:05] Challenges Regarding Transitions of Care for Medically Fragile Populations
  • No single definition for medically fragile patients
    • Without standard metrics and definitions, goals cannot be established 
    • Differences can vary based on patient needs and physician expertise
  • Patients are more complex and require many medical, social, and financial needs
    • Need physician awareness about public and private assistance and resources
  • Parental awareness, knowledge, and integration into the care team
    • Parents of children with special needs have valuable insight into their condition
  • Complicated financial considerations due to certain qualifications related to disabilities
    • Qualifications change and differ based on age, rather than considering what is developmentally appropriate for the patient and their condition 

[20:05-21:28] Six Core Elements of Health Care Transition
  • Six Core Elements of Health Care Transition
    • Approach that identifies the components of a successful transition from a youth-centered model of health care to an adult-centered model of health care and proposes steps one can take to implement the transition 
    • Model highlighted in a 2018 clinical report co-sponsored by ACP, AFP, and AAP
  • Current status of implementing this approach to health care 
    • Raising awareness, not yet at the implementation phase 
      • Financial structure may be a hindrance 
      • Without financial reimbursement or a metric for measuring how effective a transition of care is, there is a lack of incentive to implement improvements in transitions of care 

[21:28-25:26] Improving Transitions of Care on an Individual Level
  • Evaluate your current health care system, regardless of your current training level
  • Advocate for your patients
    • Understand the system, recognize gaps, propose solutions for change
  • Learn from your patients and their parents
    • Parents have gained valuable insight into resources that you can share with other patients
  • Teach others, encourage patient advocacy 
  • Network with people who share the same goals and values as you

[25:26-28:24] Inspiring Trainees to Care For Medically Complex/Fragile Populations
  • Lack of experience and appropriate training leads to some being afraid of providing care to these populations 
  • Need for inspiring trainees to care for those who are medically complex/fragile
  • Mandating complex care training, like geriatrics training, can contribute to a solution

[28:24-31:20] Learning About the Healthcare System and Health Insurance
  • Health insurance can be overwhelming, but you don’t need to be an expert to make a change
  • Network with people who have experience in what you are interested in 
  • Learn about our current healthcare system from experiences, building connections, doing research, and being transparent about what you don’t know 

[31:20-32:18] Change Starts with You
  • Change starts with you and your patient
  • Connect with your patients’ parents 
  • Change can only happen when physicians, patients, and parents work together 

[32:18-33:24] Closing

[33:24-34:36] Outro
Other resources:
NCHS 2020 Report on Children with Special Healthcare Needs: https://mchb.hrsa.gov/sites/default/files/mchb/programs-impact/nsch-cshcn-data-brief.pdf


Overview of CCS Eligible Medical Conditions: https://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx 

Credits:
Guest: Dr. Shirin Alonzo  
Co-hosts/Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman
Executive Producer: Dr. Tammy Lin 
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Tiffany Leung
Senior Producers: Dr. Maggie Kozman, Dr. DJ Gaines
Editor/Assistant Producer: Joanna Jain, Clara Baek
Production Assistants: Alexandra Babakanian, Leyna Nguyen
Website/Art Design: Ann Truong
Music: Chris Dingman
 
Disclaimer: The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with. 
 
Season 4 of The DEI Shift podcast is proudly sponsored by the American College of Physicians Southern California Region III Chapter.  
 
The DEI Shift theme music is by Chris Dingman. Learn more at www.chrisdingman.com. 
 
Contact us: [email protected], @thedeishift, thedeishift.com

Disclaimer

.The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.