Advances in pediatric gastroenterology have dramatically improved outcomes for children living with chronic gastrointestinal conditions. As a result, more patients with disorders such as inflammatory bowel disease (IBD), celiac disease, eosinophilic esophagitis, and complex motility disorders are reaching adulthood with well-managed disease. Yet the transition from pediatric to adult gastroenterology remains a vulnerable period for many young patients.
Transition is not simply the transfer of medical records or the scheduling of a first adult GI appointment. It is a structured process that prepares adolescents and young adults to assume greater responsibility for their health while ensuring continuity of care. When this process is fragmented, patients are at increased risk for lapses in care, medication non-adherence, disease flares, and unnecessary utilization of emergency services.
For pediatric and adult gastroenterologists alike, establishing a coordinated transition framework can significantly improve patient outcomes.
Start the Transition Process Early
Transition planning should ideally begin during early adolescence, typically between ages 12 and 14. At this stage, pediatric teams can begin introducing concepts of health ownership, such as understanding diagnoses, medications, and when to seek care. Gradually shifting portions of the clinical conversation directly to the patient rather than the caregiver helps build confidence and autonomy.
Tools such as transition readiness assessments can be helpful in identifying gaps in a patient’s knowledge or self-management skills. These assessments allow clinicians to tailor education over time so that by the late teenage years, patients are comfortable managing medications, scheduling appointments, and communicating with healthcare providers.
Prioritize Structured Communication Between Providers
One of the most critical components of successful transition is clear communication between pediatric and adult gastroenterology teams. A concise but comprehensive clinical summary should accompany the patient’s transfer. This summary should include disease history, prior procedures and imaging, medication history, response to therapies, surgical interventions, and psychosocial considerations.
Whenever possible, direct provider-to-provider communication can further strengthen the transition. A brief phone call or secure message between physicians can clarify nuances that may not be fully captured in documentation. In complex cases, joint transition clinics or shared case reviews can provide additional continuity.
In my own practice, I have found that a more personal approach to handoff can make a meaningful difference. In addition to sending a concise clinical summary through our shared EMR, I make a direct call to the receiving adult gastroenterologist to ensure alignment and confirm they are comfortable assuming care. This brief touchpoint allows for clarification of nuances that may not be fully captured in documentation and helps reinforce continuity for the patient.
Prepare Patients for Differences in Care Models
Adult GI care often operates differently from pediatric practices, and preparing patients for these changes can reduce anxiety and confusion. Adult clinics may expect greater independence in appointment scheduling, medication management, and communication with the care team.
Discussing these expectations in advance helps normalize the shift. Encouraging adolescents to speak directly during visits, refill their own prescriptions, and maintain a personal understanding of their treatment plan can ease this adjustment.
Address Psychosocial and Developmental Considerations
The transition period frequently overlaps with major life milestones such as leaving home, starting college, or entering the workforce. These changes can disrupt routines and make disease management more challenging.
Clinicians should consider social determinants of health, mental health support, insurance changes, and access to specialty care when planning the transition. A multidisciplinary approach involving nurses, social workers, or transition coordinators can be especially beneficial for patients with complex medical or psychosocial needs.
Integrated care models can further streamline this process. Within our practice at Texas Digestive Disease Consultants, part of GI Alliance, we benefit from strong, established relationships between pediatric and adult gastroenterologists, as well as a shared EMR platform. This connectivity allows for seamless information exchange and coordinated care, even when patients transition across state lines, such as when leaving for college. While not all practices operate within a unified system, this model highlights the value of alignment, accessibility, and communication in supporting successful transitions.
Building a Culture of Collaboration
Ultimately, successful transition requires collaboration across the pediatric and adult GI communities. By standardizing transition pathways, fostering communication between providers, and empowering young patients to take ownership of their health, we can reduce gaps in care and improve long-term outcomes.
As gastroenterologists, we have a shared responsibility to ensure that patients entering adulthood do not experience disruption in the care that has supported them throughout childhood. With thoughtful planning and coordinated efforts, the transition from pediatric to adult gastroenterology can become a bridge rather than a barrier in lifelong digestive health.
Author
Mona H. Dave, MD, Pediatric Gastroenterologist at Texas Digestive Disease Consultants, an affiliate of GI Alliance.