The development of a transition medical home utilizing the individualized transition plan (ITP) model for patients with complex diseases of childhood

Background: Advances in medicine and technology, have enabled greater numbers of children with complex illness to survive into adulthood. Adolescents with these conditions are at high risk for adverse outcomes when transitioning to adult health care. The Staging Transition for Every Patient (STEP) Program was developed to systematically improve the transition from pediatric to adult healthcare.Objective: This article details the development of the STEP program and the novel use of Individualized Transition Plans (ITP) in the clinic setting.Methods: A provider needs' assessment of the existing transition services among youth with specific diagnoses was performed, a steering committee was developed that created a transition policy, and a medical home within the adult system was established with an interdisciplinary approach. The ITP fo-cuses on 5 individualized goals, it was developed and tested with the first-year cohort of patients.Results: In the initial needs assessment, 7 of 35 diagnoses were found to have an effective transition plan. The STEP program partnered with departments across the adult facility to conduct 267 interdisciplinary patient visits. In the first year, 169 new patients were seen in the clinic. The average age was 23.0 +/- 4.1 years old. The ITP goals included referrals to adult specialists, advanced care planning, career and education, transition readiness, caregiver burden, and an emergency sick plan. Conclusion: There is a need for organized transition care for medically complex youth. The STEP program answers that need by addressing the unique needs of each patient. Individualized transition planning builds trust and addresses multiple domains of health.(c) 2022 Elsevier Inc. All rights reserved.

Automated summary

This article describes the development of the STEP program and the innovative use of Individualized Transition Plans (ITP) in the clinic setting. The STEP program improves the transition from pediatric to adult healthcare by conducting a provider needs' assessment, creating a transition policy, and establishing an interdisciplinary medical home. The ITP focuses on 5 individualized goals and has been implemented through interdisciplinary patient visits in collaboration with adult healthcare departments.