COMMENTARY

Transitioning Adolescents With Asthma to the Adult Model of Care

Mary E. Cataletto, MD, FCCP; Navitha Ramesh, MD

Disclosures

December 04, 2018

Editorial Collaboration

Medscape &

Mary E. Cataletto, MD, FCCP: Hello. I'm Dr Mary Cataletto, professor of clinical pediatrics at the School of Medicine, Stony Brook University, in Stony Brook, New York. Joining me today is Dr Navitha Ramesh, clinical assistant professor of medicine at the Geisinger Commonwealth School of Medicine in Scranton, Pennsylvania.

We are speaking to you as part of a collaboration between Medscape and CHEST. Today's discussion is about the process of transitioning an adolescent or young adult with asthma from pediatrics to the adult model of care.

Dr Ramesh, what has been your experience when you first meet adolescents or young patients with asthma in your pulmonary practice?

Navitha Ramesh, MD: I most commonly see these patients in the inpatient setting. I see them during their acute exacerbations, either in the emergency room or on the hospital floor. It is very rare that I see adolescents and young adults with stable disease in an outpatient setting.

Cataletto: Do you think your experience has been unique?

Ramesh: No. I think my colleagues have had a similar experience. These patients have the highest healthcare utilization during the transition period, and the asthma readmission rate increases in this time period, too.

Cataletto: Pediatricians have similar concerns. Adolescents and young adults are vulnerable to a lot of the morbidity and preventable visits that you are reporting during this critical period. They may have lost their support systems and may not have access to the same medical home that they had when they lived with their families. As a result, treatment adherence is an issue in these patients.

Defining Transition

Cataletto: Transition is a very important concept, which we've been talking about since the early 2000s. This is a process that is very different from the transfer of care with which most people are comfortable, and starts somewhere around the age range of 12-14 years. Basically, it is the planned and purposeful movement of teenagers through the pediatric childcare system to an adult-oriented healthcare system.

An effective transition entails you and I talking to each other. It means that the children are directly involved with what is going to happen with their life, and that we recognize their developing autonomy. We are trying to integrate them into adult care so that they can assess and build skills that allow them to become a much more functional partner with you in their care.

Interestingly, although we have been talking about this since the 2000s, it was not actually recognized by the Health Resources and Services Administration and the Child Health Bureau as an important performance measure until 2015.[1] As a result, you are going to see a lot of changes regarding the necessary services and support for that transition to adult care.

Ramesh: I agree that transition is an ongoing process, and not a one-and-done event.

The other interesting thing I found was that in 2016, the National Survey of Children's Health[2,3] sampled approximately 50,000 children and found that less than 20% of them actually received all of the three elements [doctor or other healthcare provider (HCP) discussed the eventual shift to an HCP who cares for adults, an HCP actively worked with youth to gain self-care skills or understand changes in healthcare at age 18, and youth had time alone with an HCP during the last preventive visit] during the transition period.

Cataletto: This is an important factor, and we are going to need to work harder on it.

Why an Effective Transition Is Essential

Cataletto: Transition is such a necessary yet complex process, because there are not enough pulmonologists or adult specialists who are willing to care for adolescent patients. Often, these patients do not know how to link into community support during the period when they are moving into college or into different work environments. We need a lot of staff to bring the internists and the pulmonologists into the pediatric medical homes so that patients will feel comfortable and be effectively hooked into the adult model of care.

Ramesh: From our end, it is key to give patients the right mindset. Patients often have great bonds with their pediatrician, and in that setting most everything is done on their behalf by their parents. However, when they transition into the adult world, patients will need to know more about their disease. They will also have to be confident in saying that they are a child or an adult with asthma, rather than an asthmatic. We need to get that stigma out of them and empower them with management skills.

Cataletto: Empowerment is a very important concept, and I am glad that you brought it up. Not only do they need to know that they have asthma, so they have a better sense of what they need if they go to the emergency room or the hospital, but also to know what to do before they get there by ensuring that they have a good understanding of their asthma action plan. It is not only self-management skills, but also knowing what to do when different things happen.

In terms of education, you noted that you wished they had known more about their asthma, but I think the Expert Panel Report Guidelines[4] are changing this by really emphasizing the need for education at every visit. Not only are the physicians doing it, but it can certainly be reinforced by the healthcare team. Certified asthma educators can be used in your office, which I think has added a great deal of depth to the education of patients, especially during transition.

Ramesh: That is a great point. Ideally, we would love to have both the adult and pediatric pulmonologists meet with the patient during the transition of care, but the asthma educators and social workers also play a role in this. It is good for the patients to know that there is someone familiar in the pediatric clinic and in the asthma clinic, and for them to have the rapport with the asthma educators.

Cataletto: It is important, and in a lot of ways ideal, to have an opportunity to meet as a team and include the patients. That allows you to put in place everything before they [move into the adult service], including knowing who their doctors are, making sure they have insurance and enough medication to make the transition, and understanding what to do if they have a problem.

Key Elements for Transition

Cataletto: Let's summarize some of the key elements that we have to talk about for transition. First, we need to talk to each other. We need to have summaries of patient details that help us understand which ones are more severe or have special needs.

Next, we need to teach children as much as we can about self-care skills, their medications, and identifying symptoms and triggers. This is important even as they transition from childhood to adolescence, because they have to know when they need to ask for help.

Lastly, moving into the adult model of care is an important concept. When your family is taking care of you, it is a much more cocooned environment, but when you go to school [or move out on your own], you may not have as much support. When you become an adult, you will have to establish your support systems, which are absolutely critical to transition.

This is Dr Mary Cataletto with Dr Navitha Ramesh, on behalf of the collaboration between Medscape and CHEST. Thank you so much for being here, and thank you to the audience for listening.

Ramesh: Thank you.

Suggested Reading

American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians; Transitions Clinical Report Authoring Group, Cooley WC, Sagerman PJ. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011;128:182-200.

Okumura MJ. The transition journey: time to systematically address transition planning to adult health care. Pediatrics. 2018;142:e20182245.

Scal P, Davern M, Ireland M, Park K. Transition to adulthood: delays and unmet needs among adolescents and young adults with asthma. J Pediatr. 2008;152:471-475.

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