Pediatric Chronic Illness Transition Care Model

A growing population of youth with complex chronic disease is now surviving into adulthood, thanks to the success of NICUs, improved childhood cancer treatment, and organ transplantation technology. It is estimated that they will soon comprise almost 10% of young adults, compared to approximately 1% of young adults prior to these advances in treating childhood diseases.

Yet challenges remain. When pediatric patients with complex disease transfer to adult care, the triple threat of serious disease, immature executive judgment, and loss of usual care sources lead to a rise in preventable disability, hospitalization, and health care spending.

CERC design fellows found three failure points in current methods of managint the transition, which the  care model addresses with these core elements:

·      Help patients and their caregivers develop the knowledge, beliefs, and skills to successfully self-manage in a less nurturing adult care system.

·      Provide close support for a safe on-boarding in the adult care system.

·      Establish connection between pediatric specialty providers and new adult care providers, who are often unfamiliar with severe childhood-acquired illnesses. Providing a smooth transfer helps families avoid unnecessary worsening of disease, such as transplant organ rejection, and the costs associated with emergency room use and hospitalization.

A conservative estimate of cost savings from national implementation of the CERC transitions model is $200 million dollars in direct health care spending per year. Annual savings are likely to grow as more and more children with complex chronic illness survive into adulthood.

Authors: Rachel Bensen, MD, Dana Steidtmann, PhD, Yana Vaks, MD, Terry Platchek, MD, Donna Zulman, MD, MS, Arnold Milstein, MD, MPH

Related Publications by CERC Faculty and Fellows


Better Health, Less Spending: Redesigning the Transition from Pediatric to Adult Healthcare for Youth with Chronic Illness

Published online 2015 Oct 21. doi: 10.1016./j.hjdsi.2015.09.001