Health care transition (HCT) is the process of transitioning a patient from a pediatric care model to an adult care model. Children and youth with epilepsy (CYE) transitioning to adult care may face additional access to care challenges. Pediatric and adult providers must be able to bridge the gap and work in conjunction with other health care professionals to insure effective and efficient care delivery. Proper transition planning ensures that everyone receives the necessary services to achieve a smooth transition into adult life. More information on supporting the health care transition from adolescence to adulthood in the medical home is available in an AAP Clinical Report.

Epilepsy-related Considerations for Health Care Transition

Children and youth with epilepsy have distinctive health care needs, and several factors should be taken into account during the health care transition process. Medication management, dietary restrictions, and social and emotional considerations will make the health care transition process unique for each CYE patient.

The American Epilepsy Society recommends that CYE begin to work on their transition plan from pediatric care to adult care at around ages 10 to 13. The end goal of transitioning is to empower young adults living with epilepsy to self-manage their medical care, prescriptions, and diet. For CYE with cognitive/intellectual difficulties, it may not be possible to self-manage some or all aspects of care. Health care transition discussions for CYE impacted by cognitive/intellectual difficulties should be tailored to each patient’s level of developmental abilities while engaging caregivers as appropriate.

Implementing the Health Care Transition Process in Pediatric Medicine, Family Medicine and Internal Medicine Practices

To develop and implement a transition process, physicians can utilize the Six Core Elements of Health Care Transition™ from Got Transition® in pediatric medicine, family medicine, and internal medicine practices.

Implementing the Health Care Transition Process in Adult Practices

The National Coordinating Center for Epilepsy, in collaboration with the American Academy of Neurology (AAN), the Child Neurology Foundation (CNF), and Got Transition®, has developed a Health Care Transition Toolkit for Adult Clinicians. The toolkit is also available in Spanish. The tools in this resource can be used by adult health care clinicians to support young adult patients throughout transition to and integration within their practice. All the tools in this toolkit are examples; practices are encouraged to tailor each tool to meet the needs of their patients.

The Center has also created a series of animated video to provide information about how to use the toolkit.

Coding and Reimbursement

Additional Resources

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American Academy of Pediatrics