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Life as a teenager and older adolescent is defined by turbulence. Normal body changes and hormonal shifts cause emotional and social challenges. As high school ends and adulthood begins, this population will assuredly experience questions about their personal identity, goals, and relationships.

Throw in a chronic medical condition, such as asthma that requires diligent care planning, and you’ve got the perfect storm for constant confusion, anxiety, and uncertainty. Nothing stays the same, especially when the time comes to leave the confines of a pediatric healthcare facility to enter an adult clinical setting.

“We know that this is a time of transition,” says Suzanne Ngo, MD, assistant professor at the University of Colorado Anschutz Medical Campus, where she and a group of clinicians oversee a program that assists asthma patients as they relocate from Children’s Hospital Colorado to the healthcare providers who will help them manage their condition as they grow older. 

“You’re learning to be more independent. You’re not as reliant on your parents to help take care of any chronic disorders,” said Ngo. “This is a very vulnerable time where there are many other priorities that managing their health may get pushed down on their list. Knowing that, there has been a bigger push across all specialties for having a more planned-out approach to how we prepare patients.”

On the receiving end of these patients are physicians like John T. Watson, MD, a pulmonologist at Sentara Health in Charlottesville, Virginia, who says his primary goal for the new patients he meets is to continue a plan of care that ideally is already working well in maintaining effective disease control. Through established protocols, two-way communication, and new treatment strategies, Watson and other clinicians also have significant roles in supporting continuity for patients as they age with the disease.

Unpredictability at Any Age

As Ngo sees it, asthma is unique in its ability to be manageable while posing a constant threat of an emergent exacerbation.“Asthma differs from other disorders,” she said. “Patients can go for stretches at a time without having any symptoms and then acquire an infection or an allergy trigger and have a bad flare that can be life threatening. Because of that, there is an importance that we guide this type of transition.” 

Launched in 2020, the program at the University of Colorado initiates an action plan for each patient, one that typically begins as early as age 18. This plan helps young adults navigate the earliest steps of their continuing healthcare journey and connects them with the initial clinicians they’ll see in adulthood. The program also offers education that’s intended to empower patients as they think through their own healthcare decisions for the first time; assistance with electronic health record (EHR) system integration to ensure the transition of care; and resources for those who need additional support. Additionally, the program collaborates with the patient’s new medical team to discuss all necessary background information.

“It’s not just about having them see an adult doctor once they age out of the pediatrician’s office; it’s also about helping them gain the tools to manage their own disease,” Ngo said. “It’s knowing which medications to take and when to take them, when to seek care based on symptoms, and how to make appointments.” 

One of the more essential conversations she says is necessary as the transition unfolds centers around medication adherence for those who have stable symptoms. “That can lead to the idea that you don’t have to take your medications,” Ngo said. “There are more risk-taking behaviors at this age. That prefrontal cortex may not be fully developed, and patients might not understand the long-term consequences of certain actions. In this age group, if they get lost to follow-up and are not being continuously monitored, they may think they’re doing fine and stop their medication.”

Also adding to the volatility today is the role of climate change, which has progressively become a more worrisome external trigger for all ages, said Purvi Parikh, MD, an allergist and immunologist in New York City who operates her own practice, Allergy and Asthma Associates of Murray Hill, and serves as a spokesperson for the nonprofit Allergy & Asthma Network. Other complicating factors include poorer air quality; an increase in wildfires and severe storms creates more aerosolized pollen that can lodge deep into the lungs and leave mold behind. “When there’s flash flooding, it’s creating a sudden moldy environment that is not good for patients with asthma and those with other respiratory health problems,” said Parikh. All of these elements have become important areas of focus when patient transition is initiated.

Preparing for the Inevitable Move

At Phoenix Children’s Hospital, Cindy Salm Bauer, MD, division chief of allergy and immunology, has lost count of how many times she’s told her young patients that they’re going to walk into the facility on an otherwise ordinary day and decide that the colorful walls, bright lights, and overall kid-friendly nature are no longer inviting. “And they always laugh it off and tell me how much they love it here, but they do get ready to leave,” she said. “They don’t need small chairs or games to play on the wall. That’s just readiness and maturity. And then we work with them to make the transition.”

When patients display this type of sentiment, Bauer and her colleagues begin to prepare them for relocation by asking them to become comfortable with explaining their clinical history and present condition. They practice discussing routine but important questions related to their current specific symptomatology, prescription status for refills, and the names and indications for all prescribed medications. “And they need to be able to speak to the names of their medications,” Bauer explained. “They can’t say ‘the blue cream’ or ‘the red inhaler.’ We also want them to know the pharmacy location that’s most convenient for them. And those are the times where it’s very easy to transition.”

At the University of Colorado, patients complete the pediatric program by meeting with a nursing coordinator in person or via telemedicine to prepare for next steps, and then visit with the new physician. “Some patients may want to stay with their doctor through college, but generally we start moving patients between ages 18 and 22 years old. The general recommendation has been that by the age of 14 we should be introducing the idea,” Ngo said. 

Clinically, if there are no comorbidities that would prevent a transition, the only likely roadblock would be a conflicting schedule for ongoing allergy shots that could interfere with the patient’s overall health if a change of venue were to take place. “There would be risk to the patient that they’d have an allergic reaction due to minute differences in the preparation of extracts,” said Bauer. “To switch to an entirely different office, it would not be ideal. And the patient wouldn’t want to have to start over or step back significantly in the middle of this treatment.”

Comprehensive communication should also extend to receiving physicians and be a two-way dialogue, whether they’re in-network or external, said Bauer and Ngo. The most effective approach to this is through transferring detailed care plans along with the patient. “ Having a written plan of action helps to ensure that all patients know certain skills by a certain age, or certain stages of the disease process, and can perhaps make for a better gradual transition,” added Ngo. Ideally, end-of-visit summaries will be among the information provided and entered into the new facility’s EHR so that the patient is that much more engrained prior to the first official visit. 

“And adjustments made based on the new provider’s experience are also welcomed,” said Bauer. “The patient can trust that their prior care was top notch and that the new person is going to be on the same wavelength of care.”

Receiving Patient Transfers

Watson agrees that documented notes are a major component of successfully easing the transfer process for pediatric patients. “It’s important that when patients get to their next provider to bring notes from that previous doctor because that’s really helpful to continue continuity of care,” he said. Beneficial insights, from his perspective, include a complete understanding of symptoms and triggers, level of current control, pulmonary function testing, list of non-asthma medications that have worked well and failed, and other strategies that proved effective. “Having that history is very helpful so that we don’t repeat the same treatments that were not helpful before, or were unnecessary,” he said.

Watson was diagnosed with asthma at a young age, and he believes this helps foster trust with his patients. But he remains diligent about his intake protocol once he receives a new patient. “As a pulmonologist, having asthma gives me a lot of identification with patients in terms of their experiences in dealing with the condition,” he said. “But I think the process for new patients totally depends on their history. My job is to partner with patients and to continue what has worked [for them], or to come up with new suggestions or tweaks that may be helpful in controlling their symptoms.” 

Advancing With Therapies

With the prevalence of asthma increasing, according to the CDC, Ngo and others hope that newly developed treatment approaches continue to impact outcomes.“There is an idea that a good number of adolescents will ‘outgrow’ their asthma, but asthma is very heterogenous and there are many different courses that it can take,” said Ngo. “One thing to be careful of is not writing off those patients who believe their asthma is gone.”

Among the more promising options are Single Maintenance and Reliever Therapy (SMART), which combines corticosteroids and long-acting beta-agonists to help open the lungs. “This development has been very helpful for moderate-to-severe asthma, being it is the same inhaler used for daily control as well as the ‘as-needed’ reliever,” said Bauer. “SMART therapy has introduced a major shift in the way asthma is treated and has shown to better prevent serious attacks and overall lessen the steroid burden.” 

Other improvements include biologics for children aged 6 and older. These monoclonal antibodies are designed to reduce the inflammatory pathway that causes symptoms and offer an array of targeted treatment options with fewer side effects, as well as a reduced need for systemic steroids. “Most can be administered at home and can range from weekly to monthly dosing, which offers convenience compared to daily dosing of most other asthma treatments,” Bauer said. Phoenix Children’s is currently involved in two studies focused on asthma prevention, including the use of an oral product that Bauer said signals a shift toward proactive, personalized care as opposed to reactive treatment.

Watson envisions advanced biologics to be more common in care. “Over time, I would expect that these types of medications [will] become more of a standard and may be used earlier on in the management of asthma, as opposed to waiting for patients to have failed some of the inhalers first before moving on to them,” he said. 

Although biologics are not suitable for all patients, Parikh remains enthusiastic about future care delivery. She said candidates for biologics are those who have maxed their inhaler but still experience asthma attacks, those who require oral steroids, or those who are going to the hospital multiple times per year. “We can now personalize asthma treatments down to the cellular level,” she said. “This is an exciting time for people who have asthma and allergies because of these personalized treatments.”

Bauer, Ngo, Parikh, and Watson report no relevant financial relationships.