Transitional medicine

The Comprehensive Care Clinic at Geisinger Health System
Geisinger’s Comprehensive Care Clinic (CCC) is designed for adolescents and young adults with a pediatric acquired chronic medical condition anticipated to remain through adulthood. These conditions may include cystic fibrosis, adult congenital heart conditions, developmental delay/autism, technology dependence (tracheostomies, feeding tubes, vagal nerve stimulators, chronic vents, baclofen pumps), cerebral palsy, chromosome abnormalities, and epilepsy, among other diagnoses. Established in 2012 to aid in transition, the clinic has evolved into a unique health care delivery model providing not just transitional services but also becoming a medical home to the most medically complex.

Patients are seen on a two-tiered model. Patients 15 years and older can be seen as a consult to help guide both the patient and their family through the transition process as well as co-management of complex disease. Patients over age 18 years can be transitioned to the CCC as their primary care provider and receive all care in one location. All patients and their families are evaluated for transition readiness using the six steps to a successful transition.

The CCC is staffed with an interprofessional team allowing an overall assessment of the patient’s medical condition, formalized development of a patient-centered transition and management plan, along with review and education related to community resources and waiver programs. 

Resident experience
All residents are involved in the CCC as part of their Med-Peds ambulatory curriculum. The resident experience progresses over the four years from structured observation to active patient management.A formal elective experience in transitions of care rotation is being developed. Residents with a special interest in the medically complex pediatric population and transitions of care have the ability to be involved in the ongoing research and quality improvement projects that are integrated with the CCC.

Frequently asked questions related to transitional medicine

Why is transition important?
Health care advances have medically complex pediatric patients living longer, necessitating entry into an adult centered care model. The 2009-2010 National Survey of Children with Special Health Care Needs showed that there are more than 11 million children with special health care needs nationwide and more than 470,000 children in Pennsylvania alone. Now, more than 90 percent of children with a chronic disease live past their 20th birthday.

What is the transition of care?
Health care transitions is defined as the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child centered to adult-oriented healthcare system. The overarching goal for transitional medicine is to provide high quality, coordinated, uninterrupted care which is responsive to the needs and desires of the patient as well as his or her family while enhancing the sense of self-determination and self-advocacy.

This pediatric transition of care is the process of preparing a pediatric patient with a chronic condition to see adult physicians and specialists. It involves a partnership, close communication and planning with the child’s pediatric primary care provider, an adult primary care provider and both pediatric and adult specialists. The goal is to provide consistency and no lapse of care. (National Dissemination Center for Children with Disabilities)

The transition of care also includes educating the pediatric patient to take an active role in understanding their medical problem(s), medication(s), and asking their physician questions. The transition and education is a gradual process that occurs over several years.

When should this process begin?
The transition of care should start to take place with patients with a chronic condition starting at fourteen years of age. Medically complex pediatric patients with multiple providers should be incorporated at each visit. Once the transition of care has been completed, that patient will continue to follow their current family care physician or an adult primary care provider that the patient chooses.

Where can I find out more about the process?

In 2002, the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians created six steps to a successful transition of care:

  • Identify a health care provider to help guide through the transition process
  • Identify core knowledge and skills required to provide developmentally appropriate care
  • Prepare an up-to-date medical summary
  • Create a written transition plan by age 14
  • Apply the same guidelines for primary and preventative care for all adolescents

Ensure affordable, continuous health insurance.

An expert consensus statement on the transition of adolescents to adulthood in the medical home can be found in Pediatrics. (Pediatrics 2002; 110;1304-1306 and Pediatrics 2011; 128; 182-200). Another great resource is www.gottransition.org.