First, we need to assess the patient's knowledge and skills. A questionnaire will be sent to the patient to fill out. Another questionnaire will be provided to families and caregivers to assess the patient's knowledge and skills from their perspective. The transition team will review the survey results and form the transition goals. The goals will be clear and shared with the patient and family. The family and caregivers will provide support to help the patient achieve their goals.
There will be a different survey for each age group. We ask the patient and caregivers to update us using age-appropriate surveys as we help them achieve their goal of independence. During this time, we'll also give the patient opportunities to practice making their own appointments, receive care without family present and make their own decisions.
Transition will take place in the pediatric clinic.
At age 18, the patient is legally considered an adult, but will continue to receive care in pediatrics unless they choose otherwise. Health care providers will talk with the patient directly and expect them to sign forms and consent to treatments.
In order to share health information with their family, the patient will need to sign a form to specify what information can be shared and with whom. Patients can ask for this form at the front desk of the clinic and can change their mind at any time.
This is the final year before the young adult is expected to leave pediatric care. Transfer of care is a process that usually takes place at age 20 to 21. During this year, social workers will play a major role and will guide the patient. There will be an emphasis on future medical insurance, finding an adult care provider, discussing eligibility for housing, transportation and community assistance if needed. We will help the young adult find an adult care provider that accepts their insurance. Some patients may choose to alternate visits between that provider and pediatrics during this final year.
Some patients in cardiology, hematology/oncology and general pediatrics will continue their care in pediatrics until the age of 25. Patients in the allergy and immunology clinic will continue to see their provider through adulthood.
A checklist for the transfer year helps ensure the following: