Transition to adult care is when a pediatric patient plans for and prepares to receive care from the adult side of the health care system.

Transfer to adult care is when a pediatric patient moves their care from their pediatric provider or team to an adult provider or team.

A planned, formal transition process that starts well before transfer of care can help with:

• Continuity of patient care
• Maintaining patient health and emotional well-being
• Access and capacity for new pediatric patients
• Minimizing patient use of emergency care

Tips for helping patients transition to adult care

Transition to adult care is an active, ongoing and iterative process. The OHSU Doernbecher Pediatric to Adult Transitions in Health Care (PATH) Program is leading work to develop best practices for this process.

Start early. When patients are between ages 11 and 13, start to talk about moving to adult care. Help them and their families understand the importance of planning ahead for this big change so they don’t have gaps in their care.

Transition to adult care occurs while patients’ executive function skills are developing. Supporting patients at this time can increase their chances of successfully navigating and integrating into an adult care model.

Create transition appointments. Dedicating visits to this topic helps ensure you have time to talk with patients and families and answer their questions about:

• When to transfer care.   
• Differences in pediatric and adult care.
• How living with a condition as a child and teen can differ from living with it as an adult.
• Skills patients need to manage their health care.
• Changes in access to patient health information.
• Non-clinical aspects of transition, such as reproductive health or health insurance needs.
• Feelings about transitioning to an adult care model and transferring care.

We can provide support with billing for these appointments.

Take a team approach. Setting up a cross-functional team can help you address all aspects of the transition.

For example, the OHSU Doernbecher Pediatric to Adult Transition in Health Care Program supports each patient with a team that includes:

• A provider “champion”
• An administrator
• A social worker

Transition “champions” can also include physician assistants, medical assistants, physicians, registered nurses and others.

A team approach can help support:

• Patients who see multiple providers and need multiple transitions to adult care.
• Patients who have difficulty finding an adult provider who understands their condition and how it is cared for in a pediatric setting.
• A medical event or change in a patient’s condition that may delay transition to adult care.

Provide a range of support. You may find patients and families more likely to engage with the transition process if they have multiple ways to do so:

• Information, resources and workshops for practicing health care skills
• Support groups
• Young adult clinics
• Outreach clinics
• Resources for OHSU providers (O2 login required)

Connect with adult providers. Patients and families may feel less anxious about transfer of care if you can help them:

• Tour the adult care setting and meet team members before their first visit.
• Have a “warm transfer” with an in-person or virtual appointment that includes the pediatric and adult providers.

How adult providers can facilitate transfer

Create or look for outreach opportunities. Young adult clinics and tours of adult care settings offer ways for pediatric patients to meet you and learn about adult care.

Encourage “warm transfers.” In these in-person or virtual appointments, you get to know the pediatric patient and their pediatric provider before they start care with you. Allowing patients to bring a family member, if possible, can be helpful.

Understand patients’ expectations and experiences. Consider visiting a pediatric care setting that treats patients with the same conditions you see, to learn about differences in:

• How pediatric care is provided
• How pediatric patients experience their condition

Connect. Open lines of communication with pediatric care teams or services.