Transition of Care

A young girl discussing her pediatric transition of care

Kids with chronic or complex medical conditions can’t stay in pediatric care forever. They will need to see adult-care health care providers once they reach young adulthood. But making that transition can be overwhelming. Our Nemours pediatric transition of care team can help you plan and anticipate what may be different — from selecting adult care specialists to applying for programs in your community — so when it’s time, it’s not so scary after all.


Video Series: Becoming an Adult

Moving out of the pediatric health care world is a major milestone in every young adult's life. Learn ways for young people to be more involved in their health care and what skills they will need to be successful.



 
Read More About Pediatric Transition of Care
Nemours: A Leader in Pediatric Transition of Care

In 2008, the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., was one of the first children’s hospitals in the nation to launch a comprehensive pediatric transition of care program that covers all chronic and complex medical specialties, including cerebral palsy, spina bifida, cystic fibrosis, autism, congenital heart disease, diabetes, cancer, genetic anomalies and more.

Now, other children’s hospitals around the country are learning from us and developing their own programs. We’re proud to play a part in sharing this important initiative with children beyond our circle of care.

Nemours/Alfred I. duPont Hospital for Children, Wilmington


1600 Rockland Road
Wilmington, DE 19803
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For Appointments: (302) 651-4200

To learn more about the pediatric Transition of Care program at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., or to schedule an appointment, please contact:

Cory Nourie, MSS, MLSP

Patient Transition
Social Work Coordinator
Phone: (302) 651-4812
Fax: (302) 651-5066
Email: cory.nourie@nemours.org

Rochelle Sassler

Program Assistant
Phone: (302) 651-5502
Email: rochelle.sassler@nemours.org

Initial consultations are scheduled for the following times on the third floor of the hospital in the Neurosciences Suite:

  • Mondays, Tuesdays, Thursdays and Fridays: 9 a.m. or 10:30 a.m.
 
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What to Bring
  • photo ID
  • medical and pharmacy insurance cards
  • preferred pharmacy name and phone number
  • names and dosage of all medications, including over-the-counter medication, your child is currently taking
  • guardianship and custody papers, if a legal guardian rather than a parent accompanies your child
New Patients

Bring these forms for your first appointment:

Your first consultation is an opportunity to meet with the Transition of Care team to develop the foundation for your transition plan. To help make the consultation as productive and comprehensive as possible, you might want to bring:

  • any medical information or notes you may have regarding your child’s condition
  • the contact information for all of your child’s physicians who are not from Nemours
  • list of questions or concerns you have about your child’s continuing care
 
Forms & Resources
Resources for Patients & Families
Transition of Care Resource

Why is pediatric transition of care so important?

For teens and young adults with ongoing or serious health care needs, a successful move from pediatric to adult health care can improve their quality of life and even save their lives. That’s because far too often, young adults don’t find a regular doctor right away, stop or delay taking their medicines, or skip much-needed tests. And that can have a major impact (for the worse) on their health.  

This is why the Nemours pediatric Transition of Care program starts early: empowering your child as young as 14 years old to become as independent as possible by 21. The team works with your child and caregivers to anticipate medical and non-medical needs, and provides resources to help make the transition easier.

 
Who’s Eligible for Our Pediatric Transition of Care Program

The Nemours pediatric Transition of Care program is open to anyone 14 years or older receiving care from a Nemours physician. There are no medical eligibility requirements and the program is usually covered by insurance. Your physician can refer you to the program, or you can call us directly to start the transition process.

Although children with chronic or complex medical conditions benefit most from transition services, we believe every child gains from learning how to be self-managers of their health.

 
What to Expect From Our Pediatric Transition of Care Program

The pediatric transition of care process at duPont Hospital for Children ensures your child is ready to transition to adult care by age 21.

We start with a 90-minute consultation meeting that includes:
  • you and your child
  • senior pediatrician and program director
  • transition social work coordinator

Together, we’ll discuss your child’s medical condition, specific needs, concerns, dreams and aspirations, and so much more. The result? A written, comprehensive plan with identifiable goals, responsibilities, action items and deadlines. The best part is: you, your child and your child’s current health care providers get a copy of this very detailed clinic note, which means everyone is on the same page at times.

 
Your Pediatric Transition of Care Plan Outline
Your pediatric transition of care plan will:
  • summarize your child’s medical history, medications and treatment
  • outline specific medical opportunities and challenges
  • recommend specialists and subspecialists your child may need as
    an adult
  • discuss insurance changes and how they may affect your child
  • discuss related legal considerations (power of attorney, estate planning and others)
  • identify community/state/federal resources and financial assistance, waiting lists and requirements
  • outline your child’s education, vocation, residency, transportation, and social goals and opportunities

Because this plan is a living document, we’ll meet regularly as a team to collaborate, celebrate, reorganize and re-energize every three months, twice a year or once a year. The timeframe will depend on your child’s age, medical condition and development.

 
Successful Pediatric Transition of Care Starts Early

Just as children benefit most from care received by pediatricians trained in childhood conditions, adults, too, benefit from experienced adult-focused care. This is especially true for people who have complex medical needs.

Transitioning is a Process

Many of our patients see several doctors and it isn’t always easy to find adult care providers who are familiar with pediatric-onset conditions. By starting long before kids “age out of” (or outgrow) pediatric care, we’ll help you and your adult child be confident and prepared not only for the move to adult health care, but also adulthood.

With an early start, we can:
  • help your child learn self-management skills like setting appointments and talking to physicians, insurance companies and other health care providers
  • discuss changes in eligibility for adult community programs and services, help your child get on appropriate waiting lists, and plan for all of the non-medical aspects of life
  • take time to identify care providers in your area who can manage your child’s special needs
  • begin information sharing and goal setting with the new physician as the transition nears
  • prepare you and your child for the differences between pediatric and adult health care systems