McLaughlin Suzanne, Bowering Nancy, Crosby Barbara, Neukirch Jodie, Gollub Eliza, Garneau Deborah
Program director for the medicine-pediatrics residency at Rhode Island and Hasbro Children's Hospitals and assistant professor of medicine and pediatrics, The Alpert Medical School of Brown University.
R I Med J (2013). 2013 Apr 1;96(4):25-7.
A growing population of adolescents with special healthcare needs is aging into adulthood. These emerging adults face the transition challenges of their healthy peers but also potentially heightened risks and challenges related to their conditions. We describe the process of developing a pilot program to support healthcare services for emerging adults with chronic conditions and present preliminary data on utilization.
An outpatient multidisciplinary consult model was developed based on patient, family and physician feedback. Patients with diverse conditions were equally referred from primary care, subspecialists and families and community agencies. Services provided included needs assessments (100%), referral to adult physicians (77%), care coordination (52%) and referrals to adult community services (10%). Clinical billing did not fully support the cost of providing services.
The pilot program offered multidisciplinary transition services that were utilized by a diverse patient population. Local and national resources for health care transition are provided.
有特殊医疗需求的青少年群体日益步入成年期。这些刚成年的人面临着与健康同龄人相同的过渡挑战，但因其自身状况，他们还可能面临更高的风险和挑战。我们描述了为患有慢性病的刚成年的人开发一项试点计划以支持医疗服务的过程，并展示了关于利用率的初步数据。
基于患者、家庭和医生的反馈，开发了一种门诊多学科咨询模式。患有各种疾病的患者由初级保健、专科医生以及家庭和社区机构平等转诊。提供的服务包括需求评估（100%）、转诊至成年医生（77%）、护理协调（52%）以及转诊至成人社区服务（10%）。临床计费并未完全支持提供服务的成本。
该试点计划提供了多学科过渡服务，不同患者群体都使用了这些服务。提供了地方和国家层面的医疗保健过渡资源。
