Urology Transitional Care Program: Collaborating to Improve Care Coordination for Patients Approaching Adulthood

Children with complex congenital conditions are living and thriving far into adulthood, thanks to advances in medical care over the last several decades. As these individuals reach adulthood, they stand at a crossroads in their lives, especially when it comes to their health. “Moving on” to care in the adult world can be disconcerting for patients and families, as well as for the physician who has cared for them often since birth.

Beyond just finding a new hospital, transition often means identifying new physicians and even a new urologist, and navigating an entirely new hospital system including understanding new radiology practices, new labs, new parking and new providers. This can be daunting for anyone, but especially so for those with close and ongoing ties to a special place like Children’s Hospital of Philadelphia.

As our patients grow older and prepare to transfer to adult healthcare providers, they have traditionally been faced with somewhat limited options. Many urologists who care for adults have little training in assisting patients with complex congenital anomalies and limited experience helping them navigate the challenges they may face into adulthood. For the CHOP Urology team, maintaining a high level of care for these families remains a priority throughout their entire lives, not just during their pediatric years.

Meeting a need

Around five years ago, Division Chief Douglas A. Canning, MD, recognized he had a prime opportunity to address this challenge head on. He realized this would require a total team effort and a unique perspective — one that CHOP Urology has firmly embraced.

R. Caleb Kovell, MD Around that time, a newly minted reconstructive urologist was coming back to the University of Pennsylvania after his fellowship training. He had previously completed his residency at UPenn during which time he spent six months training directly with the team at CHOP, learning the ins and outs of the system. Fortunately, that meant our team would gain someone who knew both systems — UPenn and CHOP — and had a strong interest and background in adult and pediatric reconstructive urology. Thus, R. Caleb Kovell, MD, would join the team as a transitional urologist.

In the coming years, he would start to see patients who were preparing for transition long before they were ready to leave CHOP. He would meet them at a visit already scheduled with their pediatric urologist, giving the family a chance to see both a familiar face and also meet their future doctor. Additionally, he would become familiar with their unique stories and situations from the providers who had cared for them for many years, something that can never be replicated just by reading a medical record.

Creating a dedicated transitional care program

The process would continue over the years as patients approached adulthood. Rather than abruptly receiving an unfamiliar name of a new urologist at a new health system, patients and families would have time to make the transition at their own pace and comfort level. While many patients have made the transition over to Dr. Kovell’s clinic, he likes to say that he’s just “joining the team,” as the patient’s pediatric urologist always remains an integral part of their care.

Eventually, as patients have gotten older, some choose to be seen at the adult facility — but then, at least Dr. Kovell would be the continuity, the familiar face. Some might require procedures to be done at the adult hospital — but again, they would be meeting that same familiar doctor over there, often with CHOP providers coming to lend their experience and knowledge. For many, having an earlier “foot in the door” in the adult world has certainly made the transition smoother.

While he has been seeing transitional patients in his clinics at Penn since he returned, Dr. Kovell opened a weekly clinic at CHOP in July 2017. Since that time, he has seen an increasing number of patients each year, both individually and jointly with our established pediatric providers. The Urology Transitional Care Program at CHOP is a collaboration between CHOP and the Hospital of the University of Pennsylvania (HUP). Our entire team works closely with patients and families to create a transition plan that is right for each patient.

Given the individualized care that the CHOP and HUP teams provide, the age at which the transition to adult care occurs may vary. Through our ongoing collaboration, it is our goal to continue to improve care coordination and long-term quality of life for our patients. We hope to establish new and improved clinical care models to help deliver the best possible care to our patients as they transition into adulthood and well into the future. Ultimately, the goal of our team at CHOP Urology is to provide patients with the best urologic care at every phase of their lives.