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Bridges Transitional Care Program

Medical advancements continue to improve survival rates of children with congenital abnormalities, developmental disabilities and chronic health issues. Today, more than 90 percent of kids with chronic conditions grow to lead full, productive lives; therefore, there is a growing need for transitional care from pediatric physicians to adult-service providers.

The Bridges program is designed to help facilitate the transition from pediatric to adult care in order to avoid a lapse in care, to easily communicate vital details about a patient’s condition and to help make the transition more comfortable for the youth and adolescents involved.  

How can Bridges help?
The Bridges program encourages parents/guardians of children as young as age 12 to begin talking about the transition in care. Bridges prepares adolescents and their parents/guardians for this transition through workshops on topics such as medications, diet, exercise, safe sex, patient rights and responsibilities, and other related topics.

Bridges also provides families with a patient care binder to easily organize important health information in order to facilitate a smooth transition. Consisting of eight sections, the Bridges patient care binder keeps all vital health information in one portable tool. This tool empowers adolescents to take control of their medical condition.  

The patient care binder includes:

  • All about me: A section on basic health information, care schedule and nutrition notes
  • Medical history: Procedure/treatment history, medications, vaccine records and family medical history
  • Care providers: Current physicians, preferred hospitals and other important care providers
  • Insurance and legal documents: All information needed for insurance and secondary insurance coverage. Contact information for guardians, details of special guardian approvals and power of attorney
  • State resources: Guide to local and regional resources for patients with special health care needs
  • Transition: Detailed guide of key developmental milestones and tips for ages birth to 21 years old


Why is a transition program so important?
Every child will eventually transition from the care of his/her pediatrician to that of an adult-service physician. This transition is exceptionally challenging for youth and adolescents with special health care needs. During the transition from adolescence to adulthood, these individuals are more susceptible to experiencing a disruption in their preventive care, missing treatments and running out of medications, all of which can lead to the need for emergency care.

In addition, adult-service physicians may be unfamiliar with treatments for what was once considered a pediatric condition; and adolescents with complex medical conditions sometimes struggle to move from a familiar pediatric physician they’ve known for many years to a new, unfamiliar adult care provider.
 
To avoid these challenges, the process of transitioning to adult-service physicians should begin as soon as a child’s medical condition is established. Working as a team, parents/family and pediatricians should gradually phase in adult-service providers according to the child’s developmental ability.

Facilitating the transition
Pediatric physicians

  • Begin discussion surrounding transition with patient at age 12.
  • Initiate and maintain portable medical summary.
  • Create and provide a written transition plan to include needed services, provider of those services and who funds them.
  • Continuation of health insurance coverage 
  • Act as a resource for adult counterparts regarding "pediatric" conditions.

Adult physicians

  • Touch base with pediatric physicians regarding transitioning patient prior to physical transition.
  • Request/seek out additional information regarding "pediatric" conditions.
  • Let pediatric groups know you are available for referrals.

To contact the Bridges program:
Jeanette Carter, R.N.
Bridges Program Coordinator
Phone: (502) 629-3904
Fax: (502) 629-7331
Email: jeanette.carter@nortonhealthcare.org