March 16, 2022 — In pediatrics, many patients visit the same provider or health system from birth and age out around 22. They may find themselves lost, needing a new adult primary care provider or specialist but not knowing who to connect with or how.

Those young adults without guidance can go years, and even decades, without the routine and preventive care and disease management they need, affecting their quality of life and ability to access health care, and increasing their risk of poor disease outcomes and unemployment.

“Unfortunately, our adolescents and young adults fall off the map” said Maria Kelly, M.D., a UF College of Medicine professor, director of pediatric medical student clerkship education and medical director of UF Health Pediatrics – Tioga. “This is a problem across the board. We see this issue in our underserved patients and also in our patients who should not be at risk for a disruption in access to medical care.”

Some patients go away to school and are able to rely on student health care options in the interim to fill the gap. Others, who are not so lucky, find themselves utilizing already strained emergency facilities and paying costs incredibly higher than the cost for routine physician care. In addition, many of the visits could have been prevented with the continuation of routine medical care and preventative services.

To help address this gap at UF Health, which has over 9,000 patients within its pediatric clinics between the ages of 16 and 22 who need to be transitioned, Kelly is championing a project called “Transitioning Adolescent Children with Pediatric Care to Adult Health Care.” The initiative, formed as part of the patient care pillar of the strategic plan introduced in December by College of Medicine Dean Colleen Koch, M.D., M.S., M.B.A., aims to develop a multifaceted, interdisciplinary program linking pediatrics, family medicine, internal medicine, subspecialty programs, social workers and health coaches to successfully prepare, educate and shift adolescents and young adults from pediatric to adult providers.

The project will include assessing patients and their family members at annual appointments, starting with children ages 12-14, on their readiness to transition to an adult health care home. Using assessment results, pediatricians and specialists can address readiness gaps and better prepare patients in health care independence ahead of the transition ultimately maximizing a chance of success for the patient. For medical complex patients, Kelly said, a warm handoff can be achieved by creating concurrent visits with the pediatric and adult providers to complete the process.

Using the newly created transition policy and infrastructure of Epic, the electronic medical record, scheduling and billing system for UF Health, as well as best practices learned through a partnership with Texas Children’s Hospital’s robust transition program, Kelly said the team will soon pilot the project in the pediatrics department with interested collaborators. She will also present this project nationally in April at the Executive Leadership in Academic Medicine program’s spring session and is looking for other faculty in pediatric subspecialties to join a team of champions who will help move the project forward over time and optimize its success.

“This will be a longitudinal process that has the opportunity to grow and refine as more faculty and divisions participate,” said Kelly, a University of Florida alumna who stayed on as faculty after completing her undergraduate studies, medical school and residency training at UF. “Making sure our pediatric patients have consistent access to health care from pediatrics through adulthood is incredibly important on some many levels.”