- Email: [email protected]
When Do Pediatric Patients Graduate?
Clinical Report
www.jpedhc.org
Questions & Answers–Primary Care
Section Editors Carol Rudy, MPH, ARNP, CPNP Rockwood Clinic Pediatrics Spokane, Washington Sally Walsh, MSN, RN, CPNP Pediatric Associates of Norwood Boston, Massachusetts Jo Ann Serota, MSN, RN, CPNP Ambler Pediatrics Ambler, Pennsylvania
Reprints requests: Carol Rudy, 10720 E Fruithill Rd, Spokane, WA 99217; e-mail: [email protected] J Pediatr Health Care. (2006). 20, 358360. 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2006.05.006
358
Volume 20 • Number 5
When Do Pediatric Patients Graduate? Carol Rudy, MPH, ARNP, CPNP (Data on page 334).
1. Why so many dilemmas? When I began practicing as a PNP in the 1970s, I distinctly remember a mother with her 13year-old daughter asking my pediatrician colleague how long her daughter could continue to see the pediatrician for her health care. He said, “I see kids until they are 21 or have kids of their own, which ever comes first and I hope it is 21.” I saw a smile of relief on both Becky and her mom. Becky continued with our practice until well into college and today brings her children in for their health care. So what is the dilemma? In 30 years, many changes have occurred: 1. Many more adolescents are having and raising babies, and both the parents and infants need age-appropriate health care. 2. Adolescent health care has become more involved, with increased focus on substance use/abuse, sexual health issues, and mental health issues such as depression. 3. The attitudes of some pediatric providers have changed as well. Some do not want to provide total health care for adolescents and prefer to refer them for
contraception, mental health care, and behavioral issues. 4. Some pediatric hospitals/units and pediatric specialists are decreasing the age of patients they will see. At the same time, adult specialists are maintaining or increasing the age at which they will see patients. Some kids are caught in the middle. 2. Who is a pediatric patient? The American Academy of Pediatrics (AAP, 1988) policy statement on the age limits of pediatrics states: “The purview of pediatrics includes the physical and psychosocial growth, development, and health of the individual. This commitment begins prior to birth when conception is apparent and continues throughout infancy, childhood, adolescence, and early adulthood, when the growth and developmental processes are generally completed. The responsibility of pediatrics may therefore begin with the fetus and continue through 21 years of age. There are special circumstances (eg, a chronic illness and/or disability) in which, if mutually agreeable to the pediatrician, the patient, and when appropriate the patient’s family, the services of the pediatrician may continue to be the Journal of Pediatric Health Care
optimal source of health care past the age of 21 years.” This is a recommendation, not an exclusive course of treatment. A position statement of the Society of Adolescent Medicine (SAM, 1995) indicates “Adolescent Medicine applies to health care, professional training, health research, and advocacy related to persons age 10 –25 years. Adolescent Medicine applies to the provision of both primary and Specialty care.” The National Association of Pediatric Nurse Practitioners (NAPNAP, 2002) statement on age parameters for pediatric nurse practitioner (PNP) practice states: “The PNP is highly qualified to provide care to individuals from birth to age 21 years and in special circumstances beyond age 21 years. NAPNAP additionally supports the PNP’s role as a provider of health care for individuals older than 21 years with unique needs and for young adults during the transition to adult health care.” 3. Who should decide when a patient should transition from pediatrics to adult medical care? Ideally this decision should be made jointly by the patient and the provider. Some young adults chose to continue their pediatric health care when they go away to college. It gives them, and frequently their parents, a sense of security to know that the provider who has seen them for years is still available when needed. Many of them seldom return for care except for an episodic illness when they are home for vacation. Other adolescents remain in the community, either working or in school. If gynecology (GYN) services are not available in the pediatric office/ clinic many young women will establish with a gynecologist in the community, thus taking the first step in the transition to adult care providers. When GYN services are provided in the pediatric setting, the transition to adult services may occur at a later date. Often the patient will ask at what age he/she Journal of Pediatric Health Care
will need to find another health care provider. If not, the PNP should start discussing the transition a year before it is to occur and offer the patient names and phone numbers for several practitioners who will be able to provide their care. Insurance often plays a major role in this decision. If young adults are still covered by their parent’s insurance, it is easier to help with the transition. If the patient has been on a state Medicaid program, they may abruptly present without any insurance coverage. Talking to the teens ahead of time and helping them to research what will be available to them is very important. Do they need to establish with Planned Parenthood for their contraception and GYN care? Does the state have a basic health insurance plan that they might qualify for? If he/she is a student, is there a student health care plan he/she is eligible for? Are there any other options available? 4. Are there situations that require special consideration? When a patient is developmentally or neurologically disabled, special attention must be taken to assure appropriate care and transition. The emotional as well as the physical needs of the patient must be considered. The patient and her/his parents/caregiver have developed a relationship of trust with the PNP and should be guided through the transition process so that they can develop a comfortable relationship with the new provider. The PNP should contact health care providers in the community to determine which ones are willing and able to assume the care of a young adult with these disabilities. Networking with family nurse practitioners (FNPs) is a good place to start. Transition from pediatric to adult specialists (ie, neurology) should be instituted by the existing specialist. In my community, the pediatric cardiologists are continuing to provide care for young adults with congenital heart
disease because they, not the adult cardiologists, are the specialists in this field. (Rosen, Blum, Britto, Sawyer, & Siegel, 2003; AAP, American Academy of Family Physicians, & American College of Physicians-American Society of Internal Medicine, 2002). Adolescent mothers vary considerably depending on their age and level of maturity. Many of the younger moms live at home with their parents/caregivers and are totally dependent on them for transportation, child care, and most decision making. They are still children themselves. Some older teens are living on their own, have a job, and are trying to function independently. When a teen mom brings her baby to her PNP for health care, after the initial postpartum period is past and the baby is doing well, it is important for the PNP to sit down with her, and if appropriate her parents/ caregiver, to discuss her future health care. (Ideally this should happen during the pregnancy; however, the adolescent and family is focusing primarily on the pregnancy at that time.) Does the office have a policy? Does the teen want to continue to obtain her health care from the PNP if possible or does she want to transition to a family practice provider? If the teen is young, what role, if any, do her parents/caregivers have in guiding her decision? Every effort should be made to assure the teen receives appropriate adolescent health care in a comfortable setting. Many teens prefer receiving their GYN examinations from the PNP who they know and with whom they are comfortable. However, problems may occur when the teen has a GYN problem after hours or when the PNP is not in the office. The PNP needs to discuss possible scenarios with his/ her colleagues and identify ways to meet the patient’s needs. Are there other pediatric providers in the practice who are willing to see or give advice to patients for urgent GYN problems? What about September/October 2006 359
family practice, obstetrics/gynecology, or urgent care providers who will provide back up if needed? How can the patient obtain emergency contraception quickly if needed? Is there a Planned Parenthood clinic available to the patient in an emergency? Once protocols are in place, every teen receiving GYN care from the PNP should be given oral and written information regarding her options. The triage nurse and all the providers should also have a copy of the protocol. The PNP may want to offer the teen a prescription for emergency contraception at the initial GYN visit along with instructions for appropriate use if needed if the PNP is unsure a colleague would be willing to provide it. HOSPITALS AND SPECIALISTS Outside of major medical centers, there are few adolescent hospital units or specialists. Those fortunate enough to be close to a major center may have access to these, but what about the others? If the adolescent is older than the age accepted on the pediatric unit and is being admitted by a pediatrician or sub specialist, the physician (and PNP if appropriate) will
360 Volume 20 • Number 5
need to work with the hospital to make the appropriate decision for the adolescent to receive optimal care. Each pediatric community must discuss this issue and assure that hospitalized adolescents receive the best care possible in the most appropriate setting. 5. What can the PNP do to facilitate a smooth transition for these patients and/or families? The PNP should begin discussing the transition to adult health care services with the patient, and if appropriate the parent/caregiver, a year ahead of when the transition should occur. This provides the adolescent time to explore options while still having the opportunity to return for at least one last visit. Giving the adolescent your rationale for the transition may be helpful: “you will be having more adult health issues soon and you need a provider who is more knowledgeable about adult health.” Providing names and phone numbers of providers the PNP believes is accepting new patients and provides good young adult care is important. Reassure the adolescent that even though you will not be providing his/her health care you will continue to be
available by telephone if he/she wishes to call. Transition from pediatric/adolescent to adult health care may be a difficult time for many patients. PNPs who provide health care for adolescents must plan for this time and help each teen transition to an optimal care setting. REFERENCES American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine. (2002). A consensus statement on health care transitions for young adults with special health care needs. Pediatrics, 110, 1304-1306. American Academy of Pediatrics. (1988). American Academy of Pediatrics Council on Child and Adolescent Health: Age limits of pediatrics. Pediatrics, 81, 736. National Association of Pediatric Nurse Practitioners. (2002). A position statement on the age parameters for PNP practice. URL: www.napnap.org. Retrieved May 3, 2006. Rosen, D., Blum, R., Britto, M., Sawyer, S., & Siegel, D. (2003). Transition to Adult Health Care for Adolescents and Young Adults with Chronic Conditions. Position Paper for the Society for Adolescent Medicine. Journal of Adolescent Health 33, 309-311. Society for Adolescent Medicine. (1995). A position statement of the Society for Adolescent Medicine. Journal of Adolescent Health, 16, 413.
Journal of Pediatric Health Care
www.jpedhc.org
Questions & Answers–Primary Care
Section Editors Carol Rudy, MPH, ARNP, CPNP Rockwood Clinic Pediatrics Spokane, Washington Sally Walsh, MSN, RN, CPNP Pediatric Associates of Norwood Boston, Massachusetts Jo Ann Serota, MSN, RN, CPNP Ambler Pediatrics Ambler, Pennsylvania
Reprints requests: Carol Rudy, 10720 E Fruithill Rd, Spokane, WA 99217; e-mail: [email protected] J Pediatr Health Care. (2006). 20, 358360. 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2006.05.006
358
Volume 20 • Number 5
When Do Pediatric Patients Graduate? Carol Rudy, MPH, ARNP, CPNP (Data on page 334).
1. Why so many dilemmas? When I began practicing as a PNP in the 1970s, I distinctly remember a mother with her 13year-old daughter asking my pediatrician colleague how long her daughter could continue to see the pediatrician for her health care. He said, “I see kids until they are 21 or have kids of their own, which ever comes first and I hope it is 21.” I saw a smile of relief on both Becky and her mom. Becky continued with our practice until well into college and today brings her children in for their health care. So what is the dilemma? In 30 years, many changes have occurred: 1. Many more adolescents are having and raising babies, and both the parents and infants need age-appropriate health care. 2. Adolescent health care has become more involved, with increased focus on substance use/abuse, sexual health issues, and mental health issues such as depression. 3. The attitudes of some pediatric providers have changed as well. Some do not want to provide total health care for adolescents and prefer to refer them for
contraception, mental health care, and behavioral issues. 4. Some pediatric hospitals/units and pediatric specialists are decreasing the age of patients they will see. At the same time, adult specialists are maintaining or increasing the age at which they will see patients. Some kids are caught in the middle. 2. Who is a pediatric patient? The American Academy of Pediatrics (AAP, 1988) policy statement on the age limits of pediatrics states: “The purview of pediatrics includes the physical and psychosocial growth, development, and health of the individual. This commitment begins prior to birth when conception is apparent and continues throughout infancy, childhood, adolescence, and early adulthood, when the growth and developmental processes are generally completed. The responsibility of pediatrics may therefore begin with the fetus and continue through 21 years of age. There are special circumstances (eg, a chronic illness and/or disability) in which, if mutually agreeable to the pediatrician, the patient, and when appropriate the patient’s family, the services of the pediatrician may continue to be the Journal of Pediatric Health Care
optimal source of health care past the age of 21 years.” This is a recommendation, not an exclusive course of treatment. A position statement of the Society of Adolescent Medicine (SAM, 1995) indicates “Adolescent Medicine applies to health care, professional training, health research, and advocacy related to persons age 10 –25 years. Adolescent Medicine applies to the provision of both primary and Specialty care.” The National Association of Pediatric Nurse Practitioners (NAPNAP, 2002) statement on age parameters for pediatric nurse practitioner (PNP) practice states: “The PNP is highly qualified to provide care to individuals from birth to age 21 years and in special circumstances beyond age 21 years. NAPNAP additionally supports the PNP’s role as a provider of health care for individuals older than 21 years with unique needs and for young adults during the transition to adult health care.” 3. Who should decide when a patient should transition from pediatrics to adult medical care? Ideally this decision should be made jointly by the patient and the provider. Some young adults chose to continue their pediatric health care when they go away to college. It gives them, and frequently their parents, a sense of security to know that the provider who has seen them for years is still available when needed. Many of them seldom return for care except for an episodic illness when they are home for vacation. Other adolescents remain in the community, either working or in school. If gynecology (GYN) services are not available in the pediatric office/ clinic many young women will establish with a gynecologist in the community, thus taking the first step in the transition to adult care providers. When GYN services are provided in the pediatric setting, the transition to adult services may occur at a later date. Often the patient will ask at what age he/she Journal of Pediatric Health Care
will need to find another health care provider. If not, the PNP should start discussing the transition a year before it is to occur and offer the patient names and phone numbers for several practitioners who will be able to provide their care. Insurance often plays a major role in this decision. If young adults are still covered by their parent’s insurance, it is easier to help with the transition. If the patient has been on a state Medicaid program, they may abruptly present without any insurance coverage. Talking to the teens ahead of time and helping them to research what will be available to them is very important. Do they need to establish with Planned Parenthood for their contraception and GYN care? Does the state have a basic health insurance plan that they might qualify for? If he/she is a student, is there a student health care plan he/she is eligible for? Are there any other options available? 4. Are there situations that require special consideration? When a patient is developmentally or neurologically disabled, special attention must be taken to assure appropriate care and transition. The emotional as well as the physical needs of the patient must be considered. The patient and her/his parents/caregiver have developed a relationship of trust with the PNP and should be guided through the transition process so that they can develop a comfortable relationship with the new provider. The PNP should contact health care providers in the community to determine which ones are willing and able to assume the care of a young adult with these disabilities. Networking with family nurse practitioners (FNPs) is a good place to start. Transition from pediatric to adult specialists (ie, neurology) should be instituted by the existing specialist. In my community, the pediatric cardiologists are continuing to provide care for young adults with congenital heart
disease because they, not the adult cardiologists, are the specialists in this field. (Rosen, Blum, Britto, Sawyer, & Siegel, 2003; AAP, American Academy of Family Physicians, & American College of Physicians-American Society of Internal Medicine, 2002). Adolescent mothers vary considerably depending on their age and level of maturity. Many of the younger moms live at home with their parents/caregivers and are totally dependent on them for transportation, child care, and most decision making. They are still children themselves. Some older teens are living on their own, have a job, and are trying to function independently. When a teen mom brings her baby to her PNP for health care, after the initial postpartum period is past and the baby is doing well, it is important for the PNP to sit down with her, and if appropriate her parents/ caregiver, to discuss her future health care. (Ideally this should happen during the pregnancy; however, the adolescent and family is focusing primarily on the pregnancy at that time.) Does the office have a policy? Does the teen want to continue to obtain her health care from the PNP if possible or does she want to transition to a family practice provider? If the teen is young, what role, if any, do her parents/caregivers have in guiding her decision? Every effort should be made to assure the teen receives appropriate adolescent health care in a comfortable setting. Many teens prefer receiving their GYN examinations from the PNP who they know and with whom they are comfortable. However, problems may occur when the teen has a GYN problem after hours or when the PNP is not in the office. The PNP needs to discuss possible scenarios with his/ her colleagues and identify ways to meet the patient’s needs. Are there other pediatric providers in the practice who are willing to see or give advice to patients for urgent GYN problems? What about September/October 2006 359
family practice, obstetrics/gynecology, or urgent care providers who will provide back up if needed? How can the patient obtain emergency contraception quickly if needed? Is there a Planned Parenthood clinic available to the patient in an emergency? Once protocols are in place, every teen receiving GYN care from the PNP should be given oral and written information regarding her options. The triage nurse and all the providers should also have a copy of the protocol. The PNP may want to offer the teen a prescription for emergency contraception at the initial GYN visit along with instructions for appropriate use if needed if the PNP is unsure a colleague would be willing to provide it. HOSPITALS AND SPECIALISTS Outside of major medical centers, there are few adolescent hospital units or specialists. Those fortunate enough to be close to a major center may have access to these, but what about the others? If the adolescent is older than the age accepted on the pediatric unit and is being admitted by a pediatrician or sub specialist, the physician (and PNP if appropriate) will
360 Volume 20 • Number 5
need to work with the hospital to make the appropriate decision for the adolescent to receive optimal care. Each pediatric community must discuss this issue and assure that hospitalized adolescents receive the best care possible in the most appropriate setting. 5. What can the PNP do to facilitate a smooth transition for these patients and/or families? The PNP should begin discussing the transition to adult health care services with the patient, and if appropriate the parent/caregiver, a year ahead of when the transition should occur. This provides the adolescent time to explore options while still having the opportunity to return for at least one last visit. Giving the adolescent your rationale for the transition may be helpful: “you will be having more adult health issues soon and you need a provider who is more knowledgeable about adult health.” Providing names and phone numbers of providers the PNP believes is accepting new patients and provides good young adult care is important. Reassure the adolescent that even though you will not be providing his/her health care you will continue to be
available by telephone if he/she wishes to call. Transition from pediatric/adolescent to adult health care may be a difficult time for many patients. PNPs who provide health care for adolescents must plan for this time and help each teen transition to an optimal care setting. REFERENCES American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine. (2002). A consensus statement on health care transitions for young adults with special health care needs. Pediatrics, 110, 1304-1306. American Academy of Pediatrics. (1988). American Academy of Pediatrics Council on Child and Adolescent Health: Age limits of pediatrics. Pediatrics, 81, 736. National Association of Pediatric Nurse Practitioners. (2002). A position statement on the age parameters for PNP practice. URL: www.napnap.org. Retrieved May 3, 2006. Rosen, D., Blum, R., Britto, M., Sawyer, S., & Siegel, D. (2003). Transition to Adult Health Care for Adolescents and Young Adults with Chronic Conditions. Position Paper for the Society for Adolescent Medicine. Journal of Adolescent Health 33, 309-311. Society for Adolescent Medicine. (1995). A position statement of the Society for Adolescent Medicine. Journal of Adolescent Health, 16, 413.
Journal of Pediatric Health Care