CoIIN State Team Work: Oregon
Ensuring a medical home is available for young adults with medical complexity transitioning from their pediatrician
Lead Organization: Oregon Center for Children and Youth with Special Health Needs (Title V)
Family/Youth Engagement Partner: Oregon Family-to-Family Health Information Center
Clinical Site: Doernbecher Children’s Hospital
Project
The CMC CoIIN Oregon Team collaborated with innovative partners to ensure medical home is available for young adults with medical complexity. Together, they established an intervention focused on preparing young adults with medical complexity (YAMC) for transition from their pediatrician to an adult primary care physician (PCP).
Outcomes
To prepare the patients for this change, the team helped initiate a transition conversation between youth, family, and their pediatrician and identify a transition-focused goal for the patient and their family to work on between appointments.
Together, the team promoted shared plans of care (SPoC) as a tool to increase coordination of care among the young adults’ care providers. Additionally, the team incorporated shared decision-making among young adult, family, and providers in the SPoC approach.
