For adolescents with chronic illnesses, transitioning into adult-based care is an important part of successfully maintaining their quality of life. A new transition planning tool (TPT) created by pediatricians at Baylor College of Medicine and Texas Children’s Hospital helps healthcare providers prepare patients for this transition.

Dr. Albert Hergenroeder

The electronic medical record-based TPT enables providers to determine whether adolescents and young adults with chronic illnesses have the appropriate knowledge and skills to manage their disease as adults.

“If patients are unable to successfully make this transition, it can cause their health to deteriorate, and at times this is life threatening,” said Dr. Albert Hergenroeder, professor of pediatrics in the section of adolescent medicine and sports medicine at Baylor, who developed the tool.

Healthcare providers can use the TPT in a clinical setting to assess patients’ responses to transition readiness questions, access patient handouts and educational materials and view a summary of patients’ past responses. They can focus on a handful of questions per visit, returning to certain questions as needed until the patient answers all of them to the provider’s satisfaction. The process can be done over years, for example, starting at age 14.

The tool is general enough to be leveraged by a wide range of users including physicians, nurses, dietitians and social workers. The TPT also includes a slightly different set of questions that can be used with caregivers, parents and guardians when the patient is developmentally unable to participate.

“The success in using the tool has manifested now at Texas Children’s Hospital in 79 users across 21 services. It has also been adapted by the Epic EMR system as a Clinical Program and is distributed nationally,” said Hergenroeder.

The TPT is a part of a larger effect to facilitate the transition readiness, handoff and eventual transfer to adult-based care.