Lehigh Valley Health Network, Children’s Clinic: Providing a Smooth Transition
The Children’s Clinic at Lehigh Valley Health Network (LVHN) provides high-quality pediatric primary care and specialty care for all children. LVHN Children’s Clinic cares for children who are well, sick, and who have special health care needs, including diabetes, ADHD, asthma, ear, nose and throat problems, obesity, and other complex care needs. The Children’s Clinic provides expert, comprehensive care in a child-friendly setting through a team of professionals comprising of board-certified pediatricians, CRNPs, nurses, medical assistants, interpreters, case managers, social workers, dieticians, secretaries and referral and care coordinators.
The LVHN Children’s Clinic has been a part of the Medical Home Initiative for more than 7 years. They implemented the transition program in 2012, and have exemplified the medical home principles and model of care, as well as the transition program. The Children’s Clinic serves over 17,000 pediatric patients in the Lehigh Valley and surrounding areas, and their registry of children with special health care needs serves over 250. The transition registry, which encompasses all patients served, totals 502.
The Children’s Clinic has a large team of clinicians and staff who work together in support of their patients with special and complex health care needs. We spoke with a few members of the medical home team, including Dr. Jarret Patton, Dr. Kamini Kalola, and Damary Patton, RN, MSN. Dr. Patton explained the process for identifying children for their transition registry, which involves the need for recognizing that complex care children need an entire team to begin the conversation of transition as early as age 14. Doing so, slowly prepares the patient and family for the transition process. The initial stage of discussions happen during office visits and all necessary referrals are made accordingly. These conversations are ongoing, so the entire team - patients, parents or caregivers, doctors, social workers, care coordinators, etc. – is aware and communicating, and building a network of people to help prepare the patient and family for their transition. Dr. Patton described the transition process by stating, “Everyone remains involved along the way; it’s the same as graduating from the NICU.” With that being said, the transition is not always easy.
The work can sometimes be daunting, as adult practices deal with entirely different issues than pediatric providers. For example, young adults with tracheotomies have trouble finding adult practices because tracheotomies are a foreign concept to them. Therefore, the Children’s Clinic educates offices and assists patients in identifying adult practices that are capable of caring for their needs and performing these types of routine clinical procedures. Additionally, the Children’s Clinic uses an EMR to transfer care plans over to adult practices, in an effort to prevent any “loose ends” when patients make the transition, assure less stress for families and new providers, and ease the transition process for patients so proper care can continue to be provided.
Dr. Patton, Dr. Kalola, and Damary agree that instituting a transition policy took a great deal of time and devotion from the entire team:
We’ve experienced some growing pains with the implementation of our transition policy, but it was well worth it. Creating easy and natural partnerships was the key.
Nevertheless, the “transition is not implemented until all of the patient’s care is complete and there are no additional issues”, regardless of how long it takes to get the patient to the transition stage. The Children’s Clinic attempts to transition their patients at the age of 18 if possible, but they will continue to provide care to their patients for as long as necessary. Dr. Kalola said it best: “The transition occurs only when the patient and the family are ready to take that step.”
We had the opportunity to speak with Dr. Sweety Jain of the Family Health Center in Allentown, PA regarding the adult practice and provider perspective. Dr. Jain stated the following:
Having a Transition Coordinator (Damary Patton) has made the process of transition both effective and efficient. The Family Health Center in Allentown has transitioned many patients from the Children’s Clinic and has implemented several innovative changes in practice and through education of their staff and their physicians to help with the process of transition. Some of the efforts in this area that have been very successful are the “Patients with Disabilities as Teachers (P-DAT)” Program for the staff and physicians, extended visit slots of 40 minutes for new patients, and distribution of care packets with community resource lists to the patients. The Medical Home Project team (MHP team) which has representation from all major advocacy organizations in the community is also available to guide patients and physicians in areas they made need assistance with. One of the recent major efforts in the area of education of health care professionals in disability etiquette has been the creation of a unique video titled “Patient Voices”.
The Transition Coordinator (Pediatrics) also offers the youth and the family the option of accompanying them to their first appointment and follows up later on their satisfaction with the new practice and provider through a survey.
To learn more about LVHN Children’s Clinic, please visit their website at http://www.lvhn.org/facilities_directions/hospital_locations/childrens_clinic or contact their office at (610) 969-4300.