The adult gastroenterologist role in the early transition process is minimal as the patient only arrives to them at the end of this process around the age of 18. In general, the adult gastroenterologist should only accept the transfer after he or she has been given an adequate medical history of this patient from the pediatric provider. This will help provide optimal care as medications, and prior medical and surgical history will be important in ongoing medical care. Since the adult gastroenterologist can potentially have an even longer role in the patient’s chronic care, the transition is crucial in establishing a physician–patient relationship that fosters independence as well as confidence, trust, and communication in both parties.

The adult gastroenterologist’s role is to continue to foster this independence with the patient. The patient should continue to be the main focus and should be seen independently from the parents, especially if over-concerned parents tend to drive the visit interactions. At this time, legal implications of healthcare can also play a role. The patient is solely responsible for their medical information. It will be up to him or her to decide if and to what extent the parents should be involved. HIPAA regulations will come into play as parents, once used to obtaining and providing information, now legally does not have a role without the patient’s consent. The adult gastroenterologist and the adult care team (nurses, medical assistants) should be aware of this when parents of transitioned patients call for information. However, if the transition process is successful, the patient would be contacting the office themselves for medical information.

The adult gastroenterologist should also acknowledge the parents and work jointly to continue to allow for the patient to remain independent and communicate any issues they have at the first visit. There should be mutual understanding of everyone’s role. Since the parents have been a key player in their child’s chronic illness, it is understandable that the parents will have concerns and questions, as well as some resistance toward the transition. However, with the understanding and acknowledgement that the adult gastroenterologist’s goal is to provide optimal care for the patient, then the family, patient, and physician can work together toward the same goals.

At these initial visits, the adult gastroenterologist can also confirm that the patient has established a relationship with an adult primary care physician, especially if the patient has been seeing a pediatrician for their general health care. Specialists often take on the role of “generalist” due to their frequent interaction related to IBD visits. However, obtaining a PCP is important to provide care regarding other illnesses such as general healthcare, immunizations, screening for cancer, and for preventive care for other diseases such as hyperlipidemia, diabetes, and hypertension.

The adult team should confirm that all relevant medical records are obtained, including any outstanding information that could impact management decisions. This may warrant a phone conversation with the pediatric providers to include specific social history, developmental issues, and family dynamics that may not have been fully explained in the records. The importance of adherence to therapy should continue to be addressed at this time as well as any parental concerns. The adult provider should anticipate and answer any questions about smoking, alcohol, substance abuse, and sexuality as well as the psychosocial impacts that their disease may have. They should also educate the patient regarding the adult chronic care model.

Some system should be established to monitor both the teaching of the above skills as well as what has been learned and retained. This might be done through popup messages on an electronic medical record, where objectives and follow-up learning must be recorded by date, or a special form could be kept in the patients chart to check off each set once taught and then mastered. The patient could also be given a copy of this so they can anticipate the next steps and be prepared at each visit. A member of the healthcare team should be dedicated to documenting this process to be sure patients are making progress in becoming independent. Having set questions at follow-up visits to document what has been learned is also important. Typical questions that patients might be expected to answer at a follow-up visit are (1) can you describe your disease; (2) what are your symptoms of IBD; (3) what situations should you avoid; (4) when should you call or see the doctor; (4) what is your doctor’s or nurse’s phone number; (5) did you make this appointment; (6) have you called in one of your prescriptions for refill; (7) what health records have you collected (endoscopy reports, etc.); and (8) who is your insurance carrier. Before final transition, time should be set up to do a final review of their competence in all areas and then, when the patient is ready, preparations can be made to transition care to an adult provider. At this point the patient should already be taking care of his or her health issues where a successful outcome for transition is likely.