493 - The Transition Care Team: A Model for Accepting Complex Pediatric Young Adult Patients into Primary Care in an Adult Health Care System

Publication Number: 1473.493

Lillian Zerihun, Boston Children's Hospital, Boston, MA, United States; Saara-Anne Azizi, Boston Children's Hospital, Boston, MA, United States; Niraj Sharma, Boston Children's Hospital, Needham, MA, United States

Background: The number of young adults with chronic conditions of childhood origin (CCCO) continues to rise. The transition from pediatric to adult care is fraught with challenges that often lead to “bounce-backs” to the pediatric system, delayed transfer, ED over-utilization, increased hospitalizations, and decreased patient-provider satisfaction.

Objective: The Transition Care Team (TCT) was developed to facilitate the transition of pediatric patients with CCCO to an adult health care system, with an eye toward decreasing transition time and improving the transition experience.

Design/Methods: The TCT consists of two Medicine-Pediatrics physicians and one care coordinator. A four-step Virtual Transition Process (VTP) was developed, including 1) a transition transfer packet; 2) a TCT virtual intake visit; 3) communication between primary care and specialty providers; and 4) a TCT 6-month follow-up visit. The TCT also provided navigation for insurance and referrals to an integrated complex care management program (iCMP) for patients with greater healthcare and/or social needs. Summary statistics and qualitative patient/provider satisfaction data were collected and reported from the first 2.5 years of the TCT program (September 2022 to March 2025).

Results: 185 young adults (53% male) were referred to the TCT. The average age was 23 years (range 18–36 years). 21% had a non-English primary language. To-date, 80 (43%) have successfully completed transition to their new adult PCP, with an average turnaround time of 18.2 weeks. 13.2% were referred to the iCMP program. 41.6% required insurance changes to facilitate transfer. Younger age (OR = 0.87, 95% CI 0.76–1.00, p = 0.05) and iCMP referral (OR = 1.87, 95% CI 1.06–3.32, p = 0.03) were associated with higher odds of needing insurance changes for transition. Qualitative reporting demonstrated that stakeholders (patients, families, providers) endorsed an overall positive experience with the program and increased confidence in the transition process.

Conclusion(s): We present the design and preliminary evaluation of a novel pediatric to adult transition process for patients with CCCO. Results suggest that the TCT provides expedited PCP follow-up and key assistance with insurance and complex care navigation, which are key barriers in the transition process. Optimizing an adult healthcare system to accept complex pediatric patients is integral to the transition process, including patient and provider experience and engagement. Next steps include program scale-up, as well as a more in-depth analysis to identify key inequities and barriers to successful transition.