Transition Care

We are a team of Brigham Med-Peds clinicians whose mission it is to support patients, families, and providers through the pediatric to adult medicine transition process for patients with complex and unique medical needs, including chronic conditions of childhood origin. If you are a provider and believe that the patient merits the services of the Transition Care Team, please refer them to us via our email. We aim to facilitate a smooth, efficient, and comprehensive transfer of care.

About Us

As an attending and Clinician Innovator Fellow at Brigham and Women's Hospital, Dr. Margaret Threadgill founded the Transition Care Team (TCT) with Dr. Niraj Sharma and developed the TCT Process, to facilitate the smooth, organized, comprehensive, and easy-to-access acceptance of complex transition patients into the Brigham adult system. Dr. Sharma established the Transition Care Team with Dr. Threadgill to support young adults with complex and unique medical needs through the transition from pediatric to adult care.

The Transition Process

Our team specializes in supporting the healthcare transition of patients with complex and unique medical and psychosocial needs, including chronic conditions of childhood origin. If you believe that the patient would not merit from the Transition Care Team’s services, please use this webpage to find a provider that best meets your needs.

Here is what you can expect from the Brigham Transition Care Team process:

1. Your referring physician will provide the necessary transition documentation (as per the transition checklist).
2. We will develop the Transition Transfer Packet within 2-4 weeks.
3. The Transition Transfer Packet will then be returned to the referring physician for review and approval.
4. We will then review the packet with the patient and family during the virtual intake visit with our Transition Care Team.
5. The patient will then schedule and complete the first appointment with new adult provider.
   If the first available appointment is more than 4 weeks out, the Transition Care Team will schedule monthly check-ins with the patient/family, if they desire. Please note, patients should NOT schedule a visit with a new Brigham PCP until they have been contacted by our team
6. The Transition Care Team will follow-up with the patient/family 3-6 months after the initial appointment with the new adult provider.

Our team will be available for additional visits at the patient/family’s request, and as a resource to the referring provider, at any time. Additionally, the patient and family can expect a minimum of two scheduled virtual visits with our team:

1. The initial intake visit, where we will review the Transitions Transfer Packet.
2. The follow-up visit approximately 3-6 months after their first appointment with their new Brigham and Women’s adult provider.

Informational Brochure    Transition Checklist

Contact

At this time we are unable to take self-referrals from patients. Please reach out to your primary medical provider to initiate a referral to our team.

Referring providers can reach the Transition Care Team by email at: bwhtransitioncareteam@bwh.harvard.edu.

All patient medical record information can be sent to our team via eFax at: 617-525-0517.