White Paper

Excerpt - 

Under PPC’s umbrella, organizations, physicians and Young Invisibles came together to put out the first white paper on health care transition. Brenda Gleason, M2 Health Care Consulting, provided pro-bono expertise to develop and produce the white paper.

More than half a million young people with chronic medical conditions or diseases become adults every year. The need for appropriate, coordinated, high quality care will only increase. As the nation grapples with how to reform the health care system, focusing on those people who need care the most is an excellent place to start. As this paper and many studies make clear, “the most effective way to address chronic disease—with the aims of reducing disease burden, improving quality

of life and cutting costs—is through the implementation and action of multi- disciplinary teams.”


While much of the health reform debate is focused on ideas such as creating a public plan, forming insurance exchanges, and mandating coverage, two additional core concepts appear in proposals offered by those on both sides of the aisle:

  1. Prioritizing care for the chronically ill

  2. Improving coordination of care


Many of the proposals in Washington to reform the health care system would significantly enhance treatment, coordination and transition initiatives for this population, including:

  • Paying physicians for coordinating care and health care transition planning

  • Improving health outcomes by using a medical home model that incorporates health care transition

  • Improving health outcomes through the use of activities such as

    • Quality reporting

    • Effective case management

    • Care coordination

    • Chronic disease management

    • Medication and care compliance initiatives

  • Supporting health care transition needs from adolescence to adulthood

  • Encouraging innovative approaches to clinical teaching using models of primary care, such as the patient centered medical home, team management of chronic disease, and interprofessional integrated models of health care that incorporate transitions in health care settings and integration of physical and mental health


Collaborating with local primary care providers and existing state and community based resources to coordinate disease prevention, chronic disease management, transitioning between health care providers and settings and case management for patients, including children and young adults


The advantages of coordinated care when it comes to health care and the avoidance of costs are well-known. Research has proven “strong primary care medical homes are less likely to hospitalize children with common chronic conditions and that strong chronic-condition management and care coordination reduce both hospitalizations and emergency department visits.”


Health care transition planning and coordinated care for youth and young adults with chronic medical conditions and disabilities, just as significantly as cost reduction, will improve socioeconomic well-being for these individuals with chronic conditions and disabilities, and for all of us. When it comes to reform, starting with chronic care is the right thing to do, especially when it comes to the present and long-term future of our youth and young adults.

Request the White Paper at info@physicianparent.org

"The future depends on what we do in the present"


                           Mahatma Gandhi

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