Ansley (00:33)

Today, we’re going to hear about health care transition from a provider perspective. We’re joined today by Dr. Lisa Plotnick from Dartmouth -Hitchcock, Manchester. Welcome to the podcast, Dr. Plotnick. Tell us a little bit about your practice?

Dr. Lisa Plotnik (00:47)

Sure, thanks for having me today Ansley. I have been at Dartmouth now for going on 20 years in September. I am a board-certified internist as well as a board-certified pediatrician and an internist for anyone who might not know what that term is, is a doctor for adults. So, pediatricians take care of kids from birth to approximately age 21. Internists take care of patients from age 16 to 18 or so up to geriatrics through the lifespan. So as a med peds physician, I can take care of anyone from birth to their end of their life through geriatrics. I have been involved with the creation and running of the complex primary care clinic that was established four years ago at Dartmouth Hitchcock in Manchester. Our clinic is very small. We have approximately 800 patients and we take care of children and adults with childhood onset illness or disabilities. And those can include genetic disorders, cerebral palsy, autism, other intellectual or developmental disabilities, childhood cancer survivors. We really take care of a lot of patients who been through some very complicated healthcare in their childhood, and we sometimes assume their care as kids, sometimes as adults. And we’re also trying to provide healthcare to their family members so that we take care of the whole family unit so we can be more involved in identifying things that may be going poorly before they get to a dangerous level to try to prevent emergencies. that happen in the household and try to be there for the whole unit because taking care of a person with complex medical health conditions is challenging.

Ansley (02:42)

That is such a good introduction to the work that you do and how your clinic operates. I didn’t know that you provide care for the whole family, which I know can probably be challenging sometimes, but is so important and it’s deeply appreciated. For people who may not be familiar with healthcare transition, can you give an overview of the process from a provider perspective and how it shows up for you?

Dr. Lisa Plotnik (03:04)

So, healthcare transition, as we look at the definition, is a process that’s undertaken to both help prepare the adolescent or young adult patient and their family members who support them and we want that patient and family to feel more comfortable learning about their health conditions, the treatments that they use to stay healthy, what providers that they see. To the best of their abilities and each person has different abilities and their goal to be independent. We also need to help parents or caregivers embrace the transition and support how their young adult learns to manage their healthcare, whether that’s registering for an appointment, presenting their insurance card, checking in, calling the pharmacy. Again, to the best of their abilities. So, what managing their healthcare may look like differs from each person to the next patient. And then ultimately the transition ends with the patient having a new either primary care provider if they were seeing a pediatrician or a new specialist if they’ve been seeing pediatric specialists and becoming more comfortable with that provider. There are some primary care providers like myself where we take care of people across the lifespan, but these skills are still necessary even though they’re not changing their PCP. They may be changing their specialists. They may be changing where they get their care location building wise. If it was within a children’s hospital, if they get hospitalized, it would be with an adult hospitalist program. So having those conversations, even though they’re not leaving me as they transition into adult care, we still need to remember we have to teach them the rest of those skills.

Ansley (04:57)

That’s such a great point and I appreciate you highlighting that these skills take time and practice. It’s not overnight for families and I think sometimes a lot of families feel that pressure. So, thank you for outlining that. This is a really involved process. What are some of the challenges you’ve faced trying to support patients with healthcare transition?

Dr. Lisa Plotnik (05:17)

Well, I think there are many challenges. I’ll list a few that I feel are the top challenges that patients and families face. I think the first is identifying an adult specialist who can provide the care for this each patient’s specific needs. Additionally, patients struggle with having adequate healthcare insurance so that they can access the healthcare that they need and ultimately losing potentially their transportation. that they had all through their childhood, either as their parents providing transportation or their health insurance providing transportation. Loss of transportation prevents  people from accessing any of the healthcare that they so desperately seek.

Ansley (06:00)

That is such a big barrier and thank you for bringing light to that. You mentioned finding adult specialists can be tough. Do you have any tips?

Dr. Lisa Plotnik (06:09)

I frequently am asked for recommendations on various adult specialists. And so, I can talk from personal experience of who my patients have talked and worked with and giving feedback of, well, this went really well, or this didn’t Your specialists, if you are someone that sees a specialist, often may know their colleagues that take care of adults. So, using your pediatric specialist as a resource of who do you recommend? I see now that I’m aging out of your practice. So, they may have recommendations. Many families involved with support groups or support networks. And they may be able to talk to their friends and peers in the support group for additional recommendations within a particular geographic area. And lastly, many health plans, both Medicaid and private have nurse navigators who can help identify providers who are in network, which is always a plus, who may be a good fit for you to transition to.

Ansley (07:13)

That resource of using your care management nurse navigators in your health insurance is such a great point and often one that isn’t highlighted enough. So thank you so much for bringing that up. For many youth with chronic health care conditions, complex conditions, and disabilities, the idea of transferring from a pediatrician or specialist who’s known them forever to an adult provider can be really daunting. What information do you like to see shared between sending and receiving providers? And is there anything a youth or family can do to make the process go more smoothly?

Dr. Lisa Plotnik (07:46)

So as healthcare has evolved into large systems, sometimes transition is actually easy because it’s within the healthcare system and you’re transitioning from a pediatrician or a pediatric specialist to an adult provider that’s in the same healthcare system. So, the physical aspects of your data are fairly easy to share as long as your chart is kept up to date. And so, I think as a provider, as well as a patient, we need to work together to make sure that problem lists, and medication lists are updated and accurate. Also, it can’t hurt to bring your list of specialists that you see, especially if they are out of the system, to the first meeting or every appointment that you see your new doctors or nurse practitioners will always be well received. A list of your equipment that you use, if you have a feeding tube, if you have a wheelchair, or in -home equipment because we don’t see those at the visits. If you have a hospital bed that you’re using or a shower chair or a lift, we don’t bring those typically to the doctor’s office. So, it would be good to know that if you need new ones, we need to know what you have. If someone is transitioning to a new provider,

at the tail end or in the middle of a crisis, sometimes a warm handoff can be helpful. Say someone’s being discharged from the hospital. Even if it’s not a crisis, people can still email or pick up the phone from, have a provider-to-provider discussion. The more information, often the smoother the transition. Families can help make this process smoother by bringing information that they have. Some people have full notebooks of the entire bit of healthcare that their loved one has had from birth up until yesterday. So, bringing the notebook to visits or a summary of the health issues, the specialists that are particularly managing each problem, your medications, even immunizations, and certainly get that. first visit up and running or even offering it before the visit. And then trying to be patient with the provider because if you’ve been with somebody for 10, 20, 30 years, your new person is going to be at a severe disadvantage of not knowing all of you. And we want to learn, but it takes time. So, keep honoring our ignorance with giving us the information in a way that you feel comfortable. knowing that we will, it’ll stick in our head, but it takes a little while.

Ansley (10:36)

Those are such great specific tips and also the overall understanding of having patience that it is going to take some time in that transition period to get to know one another and the relationship, you know, takes that role with your new provider. So, thank you so much for those. I know sometimes as youth are taking on more autonomy in their healthcare transition process, learning to advocate for themselves can be nerve racking. Caregivers Youth can sometimes be nervous about learning to advocate for themselves in the healthcare transition process as they’re taking on more responsibility. And caregivers can sometimes share those nerves. What have you seen that has been helpful for families navigating this time?

Dr. Lisa Plotnik (11:19)

I think it’s really important to be open and honest about anxieties. So, if you are nervous as a parent or caregiver, your youth is probably nervous too. And so, acknowledging that and saying that let’s do this together can certainly be helpful. And as a provider, I’ve been nervous taking on new patients too. So, I think we’re all in the same boat trying to figure out what needs to get accomplished at that visit. It’s okay at any visit and especially at that first visit to ask the provider to slow down if they’re giving you far too much information or if they’re talking too quickly. Ask the information to be repeated or can we write it down for you? So many electronic records. can have more information added to the after-visit summary. So, if you need a website or a phone number, it is so easy to be able to leave with information. And if you misplace your paperwork, you can go back into the patient portal and look at those notes. But don’t guess your provider if your answer is truly no or. if they ask you if you have questions and you say no, but you really had seven questions that you really wanted to ask, but we’re afraid to, it is okay. We are here to be a team. And if you don’t feel safe that you can ask the questions, then we may not be the best team and it may not be the right fit.

Ansley (12:49)

That is such authenticity and it’s appreciated that you’ve been nervous too and you guys are a team and it’s trying to come together to serve that patient. So, thank you so much. Is there anything else you’d like youth and families to know about healthcare transition?

Dr. Lisa Plotnik (13:06)

Well, I think if there’s one thing COVID taught us is there’s a lot of transition happening. There’s been a lot of providers leaving healthcare or changing roles in healthcare. So, the people you’ve worked with for a long time are no longer there. School has changed. Delivery of in -home supports and services has changed. And so, there’s been a lot of transition. So, I think the only thing that we can expect is continued change. And so, if you’ve changed to a new provider, whether it’s a physician provider, a therapist, a physical therapist, if you are going and it just doesn’t feel right, you’re not feeling heard, your questions aren’t being answered despite advocating, if you think it’s one bad visit, try another visit and see if the next one goes better because it could have been a bad day for your provider. You might have been having a rough day and been in an interesting head space where your provider was. So see if it’s worth continuing the relationship. And if you keep having difficult visits, maybe you need to change providers and that’s okay. You shouldn’t feel judged or be made to feel less than. This is your body, your healthcare, and your loved one if you’re supporting someone and everyone needs to feel comfortable in the room.

Ansley (14:31)

That is such an important and sometimes forgotten right that we have as patients, and it’s deeply appreciated that you bring it up today. All of the work that you do in your clinic and with your patients is deeply appreciated as is your time here today. Thank you so much for joining us and giving us these wonderful insights and usable tips. It means a lot.

Dr. Lisa Plotnik (14:53)

Thank you for having me.

Ansley (14:54)

All right and thank you all to our listeners for joining us and we look forward to having you listen in next time. Have a great day, everyone.