*Purpose: To effectively transition youth to adult hepatology through a structured program and developed partnerships while promoting and maintaining optimal outcomes.

*Methods: The pediatric and adult hepatology teams collaboratively developed a transition/transfer process based on the Six Core Elements of Transition (Got Transition™). Medical criteria for transfer: >3 yrs post-OLTx, stable graft function, no significant new-onset co-morbidities. Psychosocial criteria: > 18 yrs, participated in the transition education program, assessed for transition readiness, confirmed for transfer by the peds multidisciplinary team, and youth in agreement with goals and timeline. Insurance is confirmed and a release of records obtained. A transfer package (medical summary, recent labs, final peds clinic note, final readiness assessment, operative and path notes) is provided for the adult team. Youth attend a virtual “Meet and Greet” with both teams to introduce the adult team, provide an overview of clinic and differences in care, review current care, and to confirm the first adult clinic date. A member of the pediatric team attends the first clinic to provide continuity during the “warm handoff.” Outcomes are assessed by chart review and coordinator interview at 3, 6, 12, 24, and 36 months after transfer including labs (LFTs, TAC levels/MLVI, plts, BUN, cr), response rate to medical requests, and level/amount of communication with the adult coordinator.

*Results: The program was initiated in early 2021 and currently 8 OLTx recipients have transferred care with 12 patients in queue for transfer. All have successfully completed the peds transition program, attended their Meet and Greet and first adult clinic, obtained labs as requested, and are communicating appropriately with the adult team. Outcomes are available at the 3- and 6-mo timepoint for 6 pts. Labs are within range and completed on time (n=6). Mean MLVI of the 4 most recent tac levels (n=8) was 1.31 (0.42-3.11) and was 1.7 for pts with pre/post-transfer levels (n=4). ACR was diagnosed in 1 pt at the 3-month lab point.

*Conclusions: Early results suggest that a collaborative partnership between youth and the pediatric and adult care teams coupled with a structured transition program may promote healthy outcomes for young adult OLTx recipients in the early post-transfer period to adult care. Continued follow-up for this group and the patient perspective of the process are warranted.

« Back to 2022 American Transplant Congress