General Pediatrics & Adolescent Medicine

With advances in diagnosis, surgical and medical treatment of pediatric conditions, more and more children are surviving into adulthood that previously did not. It is estimated that over 90% of children born with chronic or disabling conditions will live beyond their 20th birthday. There are now equal numbers of patients with congenital heart disease over the age of 21 as there are younger than 21. It is estimated that one of every 640 adults between the ages of 20 and 39 are survivors of cancer. People with Down syndrome will likely live into their 40’s to 50’s. Similarly, most children with cerebral palsy will reach adulthood. These persons will continue to need specialized care from either pediatric subspecialists or adult subspecialists who are expert in their conditions. However, they also will require a medical home with care provided by a primary care provider who is not only familiar with their chronic conditions, but who is familiar with the assessment of acquired “adult” conditions as well as preventive medicine.

The Adolescent Transition Clinic was designed to assist special needs patient's in transitioning from the Adolescent Clinic in a pediatric hospital to an Internal Medicine setting. Special needs patient's in their twenties continue to be seen for two to three years in the same Adolescent Clinic but instead of being seen by the Adolescent providers, they are seen by internists with specialization in Internal Medicine/Pediatrics.

Clinic Mission

The overall goal of the DMC/WSU/Children’s Hospital of Michigan Transitional Care Clinic is to provide a medical home for these growing number of patients. Specifically, the clinic aims to:

• Provide uninterrupted health care that is patient centered, age and developmentally appropriate, flexible, and comprehensive
• Educate the patient about his/her disease
• Educate the patient about the differences between adult-centered care and pediatric-centered care
• Educate families regarding potential legal issues regarding insurance and guardianship
• Promote skills in communication, decision-making, self-care, and self-advocacy
• Promote personal and medical independence, to promote sense of control over one’s health, health care decisions, and psychosocial environment
• Maximize quality of life and future potential

In addition to monitoring the patient’s chronic conditions, the Transition Clinic also addresses general medical issues that apply to all adults including:

• Healthy lifestyles such as exercise and diet
• Alcohol, tobacco, and substance abuse counseling
• Sexual health
• Cardiovascular risk assessment including monitoring of blood pressure and cholesterol levels
• Appropriate cancer screening
• Adult Immunizations

The Division of General Pediatrics and Adolescent Medicine (GPAM) at the Children’s Hospital of Michigan offers an Integrated Behavioral Health Program providing comprehensive, fully integrated care that allows medical and behavioral heath services to work together to meet the unique needs specifically for GPAM patients. The program has a proud 20 year history in developing and providing high quality integrated behavioral health care to patients at Children’s Hospital of Michigan and continues to expand and improve services to meet an ever growing need.

Integrated Behavioral Health, also known as Collaborative Care, in GPAM begins with screening tools given to patients at their medical visits. The feedback from these tools, and the subsequent conversations physician’s have with patients/families, often result in families working with one of the GPAM clinical social workers to address the concerns raised. A social work assessment is focused on identifying the specific needs of a child/family. Once needs are identified, intervention options are discussed and a comprehensive intervention plan is cooperatively developed. This plan can include medical follow up, referral to community resources or, in the event of a need for behavioral health support, a direct referral to a GPAM behavioral health program therapist.

Community Partners

Behavioral health therapists are drawn from three distinct behavioral health provider groups within the program.

The first group is a collaborative with Wayne State University’s (WSU) Psychology program. With the support of The Children’s Foundation, supervised WSU Psychology doctoral students provide direct service to clinic patients at no charge. These providers meet weekly with clinic social workers for care coordination, collaborate with physicians and meet with patients in the clinic space. With this high level of integration these providers are able to meet many of the patients’ needs.

The second therapist group is through a cooperative with The Children’s Center’s Community Outreach Division. Through this cooperative, a Children’s Center therapist is designated to see GPAM patients in the clinic. This allows for co-located, insurance based services for children who require higher intensity services. GPAM social workers meet weekly with the Children’s Center therapist to review patients and facilitate communication with physicians directly as needed.

The third therapist group of our integrated program is provided by Starr Commonwealth and is supported by a grant through the Michigan Health Endowment Foundation. This program allows patients who are experiencing significant emotional disruption as a result of traumatic experiences to receive specialized therapeutic support. These patients are able to be referred to the Starr Commonwealth Trauma Clinic for comprehensive evaluation and research based intervention proven to be effective for children with trauma. The GPAM social work team meets weekly with the clinical director at Starr to review patient needs and coordinate care. Starr Commonwealth is the newest partner with the program and there are plans to expand their services to include on site visits and a focused trauma clinic for GPAM patients.