Transitioning Adolescents and Young Adults with Medical Complexity
Children with medical complexity account for 0.5–1% of US children. These youth experience a more complex transition of care, and for the purpose of the discussion, they are defined to include youth with rare or multiple chronic conditions and with significant neurocognitive and/or mental health impairments and/or technology dependence. There are distinctly protective factors at play in the transition of this population, including continuity of care by experienced and prepared caregivers, a high frequency of continuity of living in the same home setting, and sustainable and continuous insurance coverage through public disability programs. The unique challenges in this transition process include the need to adjust the existing pediatric treatment and care plan to accommodate for needs once the person reaches adult status, the common need for legal decision-making supports, a process for more in-depth preparation of adult inpatient and outpatient healthcare teams to care for less common and complex conditions of childhood, supports and equipment in home and community settings, prolonged caregiver needs for respite and adult life training, and specialized services leading to particular billing and coding concerns.
KeywordsMedical complexity Disability Care coordination Chronic care management Shared plan of care Medical neighborhood
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