For adolescents with chronic health conditions, making the switch from pediatric to adult care can be frightening and potentially dangerous. But it doesn’t have to be that way. Dr. Keely Dwyer-Matzky , a pediatric and adult hospitalist in Rochester, N.Y., has spent the last few years working to smooth the transition for young adult patients by educating patients and their families, as well as other hospitalists.
Dr. Dwyer-Matzky, who is also an assistant professor in medicine and pediatrics at the University of Rochester, helped create an educational video for adolescents transitioning to an adult setting that explains the likely changes they will encounter and how to take charge of their care. She’s also the principal investigator on a study that examines how educational interventions like that one can impact knowledge and attitudes.
In an interview, Dr. Dwyer-Matzky said that hospitalists can help make the transition smoother for adolescents by focusing on three key areas: communication, coordination, and education.
Question: What are the big mistakes that hospitalists make during that transition period? And what are the dangers for patients?
Dr. Dwyer-Matzky: The big mistake that I’ve noticed is trying to transition a patient in a time of crisis. For example, transitioning to the adult medicine world during a major new hospitalization is really not ideal for the patient. That is one of the times when patients can be in the greatest danger, and it’s because of the possibility of medical errors due to problems with handoffs and communication. I’m fortunate, because I work in a community where the adult and children’s hospitals are all on the same electronic health record, but that’s not always the case in other communities, making the communication and coordination harder.
Question: How should it work ideally? And what advice would you give to hospitalists?
Dr. Dwyer-Matzky: Hospitalists need to work very closely with outpatient providers or primary care doctors to make these transitions. The transition should be initiated in the outpatient world, whether that be by a primary care doctor or a subspecialist. If that transition has been started in some form, let’s say from a pediatrician or an adult internist, that’s at least a place to start for the hospital. If a transition does happen in a time of crisis, which I have experienced a few times just in the last couple of months, those three areas I highlighted before – communication, coordination, and education – are critical to having a positive experience both for the patient and the hospitalist.
Question: How do you put patients at ease if the move to adult care happens during a time of crisis?
Dr. Dwyer-Matzky: This is where all three of those elements come into play – communication, coordination, and education. For instance, in the last month, I had a pediatric patient who was 21 years old and was still being followed by her pediatrician. She was admitted to the adult hospital, where she had never been before. I took over the care of the patient and luckily I already knew the pediatrician, so I called and spoke at length with him. I was familiar with the system she was coming from, so I was able to sit down with the patient and her mother and let them know I was communicating with their pediatrician and making sure nothing was omitted from the handoff.
Education is another important component. You need to educate the family and the patient about the different expectations in the adult world, highlight the aspects that are similar, and emphasize in a positive way the things that are different in adult medicine. You should also educate the nursing staff by letting them know what expectations families will have coming from a pediatric hospital. Your colleagues and the residents also need to understand that this is a significant transition and that it’s an actual process that needs to be recognized.
Question: Why is this change so significant for patients?
Dr. Dwyer-Matzky: When a patient enters the adult world, the hospitalist is really speaking to the patient for the first time and they are looking to the patient to take ownership of their health and understand their care. In a lot of ways that is very different from the pediatric world. In a pediatric hospital, the parents are often the main focus, even if the child doesn’t have a developmental disability. The parents have been present at all the visits, administering the medication, calling to make the appointments. All of a sudden, there is a huge shift to expected independence. Adult hospitalists who don’t work across the continuum tend not to understand the significance of the change. If patients aren’t prepared and educated as they grow up, then it is a huge culture change for them.
Question: Why isn’t there a standardized process for this in every hospital?
Dr. Dwyer-Matzky: Each institution is very different. You may work in a city in which you have a children’s hospital that is in a completely different health system from most of the adult hospitals. You may not even have communication within the community itself, which can make this somewhat difficult. Solutions have to be tailored to your health care system. There also needs to be more education. In the last 5-7 years, there has been a lot more emphasis on this with our children with chronic illnesses living longer. We are beginning to recognize that there are hundreds of thousands of patients being transitioned every year, but the adult community is playing a little bit of catch-up. In the next 2-4 years, we need to begin a discussion on this topic in some type of national forum so that physicians and hospitals can have references and resources for improving their transition process.
