No patient left behind: Developing an interdisciplinary transition clinic for young adult patients with congenital heart disease

Advances in pediatric cardiology care have improved survival rates among children with congenital heart disease (CHD), resulting in a growing number of adults with CHD (ACHD). Many of these individuals encounter difficulty maintaining cardiac follow-up as they transfer into adult care. Transition clinics have emerged to support continuity of care, though best practices for their design remain unclear, and implementation varies widely across institutions. This article describes the development and implementation of an interdisciplinary Cardiology Transition Clinic at an academic medical center, detailing replicable processes, highlighting challenges and successes, and reviewing implications for models of care. Collaboration amongst the Divisions of Adult and Pediatric Cardiology, as well as Departments of Psychology and Social Work, led to the development of a monthly Transition Clinic at the Pediatric Heart Center (PHC). Our clinical model and standardized intake forms, used to assess patients’ transition readiness, psychosocial needs, and potential transition barriers, evolved from literature review and interdisciplinary planning. Patient transition visits include assessments from an ACHD cardiologist and a pediatric psychologist. Clear communication between clinicians and medical staff has proven vital to maintaining a smooth transition and transfer process. PHC’s Transition Clinic offers a structured, interdisciplinary approach to assessing readiness and addressing barriers to the transfer to adult cardiac care. Our model of transition services may contribute to the further development of standardized, evidence-based approaches, helping to navigate this critical stage in patient care across institutions.