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How can a medical home support transitions in care for children and how can health IT assist with these transitions?

Throughout the course of care, a child may transition between multiple primary providers and specialists.  The transitions between primary providers and specialists may affect all children at some point, but children with special health care needs and unique circumstances, such as those with chronic conditions and foster children, more often experience such transitions.  Foster children, for example, may need to access primary care and specialty care for behavioral health and dental care providers.  They also may experience numerous transitions between primary providers.  Many states, such as Florida, Illinois, Oklahoma, and Utah (PDF - 941KB), according to a report from the U.S. Government Accountability Office, are attempting to support such transitions by establishing medical homes for children in foster care that not only provide continuous primary care, but also support comprehensive health assessments and some specialty services.  In a recent report, the Federal Expert Work Group on Pediatric Subspecialty Capacity (PDF - 609 KB) concluded  that pediatric subspecialty care and health outcomes for all children, especially those with chronic conditions, will be enhanced through more effective collaboration by primary and specialty providers within medical homes.

The need for care by multiple providers may also increase as a child transitions into and through adolescence.  An issue brief from the National Alliance to Advance Adolescent Health (PDF - 498KB) notes that in adolescence, children develop a greater need for a combination of primary and preventative care.  They propose a medical home comprised of a team of various medical professionals, along with additional specialists such as behavioral health providers and gynecologists, to provide appropriate services to accommodate the adolescent's needs.  The medical home can become more patient-centered, as opposed to mainly family-centered, due to the adolescent's growing ability to take a more active role in his or her care.  A patient-centered focus on care can also assist in the adolescent's transition to adulthood.  For example the Young Men's Health Clinic at Boston Medical Center , founded and directed by Dr. John A. Rich, provides comprehensive primary care to young men transitioning from adolescent to adult care. 
While providers within the medical home can support these transitions in care, the application of health IT can support a fully implemented medical home.  Health IT can promote communication between primary providers and specialists in the medical home through technologies such as electronic health records (EHRs) and telehealth.  Information can also be shared through personal health records (PHRs) between providers and patients and families in order to assist transitions in care.  MiCare, a PHR sponsored by the Department of Defense, exemplifies how a PHR can facilitate transitions in care.  This PHR for active military personnel and their dependents, retired veterans, and reservists includes information from the patient's electronic health record to provide a patient-centered health record that is available to families through transitions between military and non-military providers and changes in the families' locations.

Related Resources:

• Medical Home Portal: Transition Issues - (Department of Pediatrics, University of Utah)
• A discussion of how health IT can support  transitions in inpatient settings - (AAP, Volume 122, Number 6, December 2008, pp. 1288-1289, 1292) (PDF - 120KB)