CENTER FOR HEALTH CARE TRANSITION IMPROVEMENT
IMPLEMENTATION AND EVALUATION
OF TRANSITION QUALITY IMPROVEMENTS
IN PEDIATRIC AND ADULT SETTINGS
Peggy McManus, MHS
Got Transition/Center for Health Care Transition Improvement
The National Alliance to Advance Adolescent Health
Greenville Health System
Transitional Care Conference
May 15, 2015
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Disclosures
• I have no commercial relationships to disclose.
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Presentation Learning Objectives
1. Understand latest developments in clinical and measurement
tools for transition from pediatric to adult health care.
2. Review examples of QI strategies to incorporate transition
core elements into 3 types of practices/systems: academic
primary care settings, academic subspecialty clinics, and a
Medicaid managed care plan.
3. Identify innovative payment strategies for transition.
4. Learn about new health care transition resources for youth
and families.
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Transition Goals
• To improve the ability of youth and young
adults to manage their own health and
effectively use health services
• To ensure an organized clinical process in
pediatric and adult practices to facilitate
transition preparation, transfer of care, and
integration into adult-centered care
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Got Transition/Center for Health Care
Transition Improvement
• Funded by federal Maternal and Child Health Bureau
to:
1. Spread transition quality improvements
2.
3.
4.
5.
Provide education/training to health professionals
Expand youth/young adult and family engagement
Improve transition policy
Serve as a clearinghouse (www.GotTransition.org)
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Making the Case for Transition Improvements
Health is diminished:
• Youth often unable to name their health condition, relevant medical
history, prescriptions, insurance source
• Adherence to care is lower and medical complications are increased
• Youth and families are worried
Quality is compromised:
• Youth, young adults, and families are dissatisfied about lack of
preparation, information about adult care, vetted adult providers,
communication between pediatric and adult providers, and sharing of
medical information.
• Discontinuity of care and lack of usual source of care are common
Costs are increased:
• Increased ER, hospital use, and duplicative tests result
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US and SC Transition Performance
• National data – from 2009/10 – show that 60% of YSHCN are not receiving
needed transition support:
– Health care providers (HCP) discussed shift to adult provider
– HCP encouraging youth to take responsibility for own health care
needs
– HCP discussed changing health needs as youth becomes adult
– Discussed future insurance needs
• SC – show that 59% are not receiving needed support – similar to US
• However, these national findings overstate transition performance -- if
perceived need was removed from the transition question, results would
show that 90% of YSHCN are not receiving transition support.
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State of Health Care Transition from
Pediatric to Adult Health Care
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AAP/AAFP/ACP Clinical Report
on Health Care Transition*
• In 2011, Clinical Report on
Transition published as joint policy
by AAP/AAFP/ACP
• Targets all youth, beginning
at age 12
• Algorithmic structure with:
– Branching for youth with special
health care needs
– Application to primary and
specialty practices
• Extends through transfer of care to
adult medical home and adult
specialists
Age
12
Youth and family aware of transition policy
Age
14
Health care transition planning initiated
Age
16
Preparation of youth and parents for adult
approach to care and discussion of
preferences and timing for transfer to adult
health care
Age
18
Transition to adult approach to care
Age Transfer of care to adult medical home and
18-22 specialists with transfer package
*Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home(Pediatrics, July 2011)
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Six Core Elements of Health Care Transition:
QI Model
• Original Six Core Elements (1.0), developed in 2011, as QI
strategy based on AAP/AAFP/ACP Clinical Report algorithm
with set of sample tools and transition index
• New Six Core Elements (2.0), developed in 2014,
incorporate results from several transition learning
collaboratives, reviews by over 100 pediatric/adult clinical
experts and consumers, and extensive review of literature
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Six Core Elements of Transition
• Discuss
Transition
Policy
AGES 14-15-1617-18
• Assess skills
• Track
progress
AGES 14-15-1617-18
AGE 12-14
AGES 14-15-1617-18
• Develop
transition
plan
• Transfer
documents
3-6 months
after transfer
• Confirm
completion
AGE 18-21
1
2
3
4
5
6
Transition
Policy
Transition
Tracking
and
Monitoring
Transition
Readiness
Transition
Planning
Transfer
of Care
Transition
Completion
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Six Core Elements 2.0
(See Side-by-Side Handout)
Transitioning Youth to
Adult Health Care Providers
(Pediatric, Family Medicine, and Med-Peds Providers)
Transitioning to an Adult Approach to
Health Care Without Changing Providers
(Family Medicine and Med-Peds Providers)
Integrating Young Adults
into Adult Health Care
(Internal Medicine, Family Medicine, and Med-Peds Providers)
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Transitioning Youth to Adult Health Care
Providers: A Closer Look
• For use in pediatric practices and family medicine
and med-peds caring for teens who will be leaving
their practice
• Other 2 packages follow 6 core elements, but are
modified for: youth not changing their provider and
for young adults going into adult health care
• Keep in mind that these can be customized with your
own practice or health plan logo
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Element 1. Transition Policy
• Make larger
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• Sample transfer letter provided to adult provider with
– Appropriate documentation (readiness assessment, medical summary and emergency care
plan, plan of care and decision support documents and condition fact sheet, if needed)
– Statement that the youth’s care is covered by pediatric practice until first visit
– Offer to be a consultant as needed
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One Measurement Option
Initial Health Care Transition Assessment
(Handout)
• Qualitative self-assessment tool
• Provides a snapshot of where practice is in
implementing transition processes
• New questions on consumer feedback and
leadership
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Core Element #1: Policy
 Level 1:
 Level 2:
 Level 3:
 Level 4:
Clinicians vary in their approach to health care transition,
including the appropriate age for transfer to adult providers
Clinicians follow a uniform but not a written policy about the
age for transfer. The approach for transition planning differs
among clinicians.
The practice has a written transition policy or approach,
developed with input from youth and families that includes
privacy and consent information and addresses the practice’s
transition approach and age of transfer. The policy is not
consistently shared with youth and families.
The practice has a written transition policy or
approach, developed with input from youth and families
that includes privacy and consent information, a
description of the practice’s approach to transition, and
age of transfer. Clinicians discuss it with youth and
families beginning at ages 12 to 14. The policy is publicly
posted and familiar to all staff.
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#2: Tracking and Monitoring
 Level 1:
 Level 2:
 Level 3:
 Level 4:
Clinicians vary in the identification of transitioning youth, but
most wait until close to the age of transfer to identify and
prepare youth.
Clinicians vary in the identification of transitioning youth, but
most wait until close to the age of transfer to identify and
prepare youth.
The practice has an individual transition flow sheet or registry
for identifying and tracking transitioning youth, ages 14 and
older, or a subgroup of youth with chronic conditions as they
progress through and complete some but not all transition
processes.
The practice has an individual transition flow sheet or registry
for identifying and tracking transitioning youth, ages 14 and
older, or a subgroup of youth with chronic conditions as they
progress through and complete all “Six Core Elements of
Health Care Transition 2.0,” using EHR if possible.
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#3: Readiness
 Level 1:
 Level 2:
 Level 3:
 Level 4:
Clinicians vary in terms of the age when youth begin to have
time alone during preventive visits without the parent/caregiver
present. Transition readiness is seldom assessed.
Clinicians consistently offer time alone for youth after age 14
during preventive visits without the parent/caregiver present.
They usually wait to assess transition readiness/self- care skills
close to the time of transfer.
The practice consistently offers clinician time alone with youth
after age 14 with clinicians during preventive visits, and
clinicians discuss transition readiness/self-care skills and
changes in adult-centered care beginning at ages 14 to 16, but
no formal assessment tool is used.
The practice consistently offers clinician time alone with youth
after age 14 during preventive visits. Clinicians use a
standardized transition readiness assessment tool. Self-care
needs and goals are incorporated into the youth’s plan of care
beginning at ages 14 to 16.
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 Level 1:
 Level 2:
 Level 3:
 Level 4:
#4: Planning
Clinicians vary in addressing health care transition needs and goals.
They seldom make available a plan of care (including medical
summary and emergency care plan and transition goals and action
steps) or a list of adult providers.
Clinicians consistently address transition needs and goals as
part of the plan of care. They usually provide a list of adult
providers close to the time of transfer.
The practice partners with youth and families in developing
and updating their plan of care with prioritized transition goals
and preferences for securing an adult provider. This plan of
care is regularly updated and accessible to youth and families.
The practice has incorporated transition into its plan of care
template for all patients. All clinicians are encouraged to
partner with youth and families in developing transition goals and
updating and sharing the plan of care. Clinicians address needs for
decision-making supports prior to age 18. The practice has a vetted
list of adult providers and assists youth in identifying adult providers.
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#5: Transfer of Care
 Level 1:
 Level 2:
 Level 3:
 Level 4:
Clinicians usually send medical records to adult providers
in response to transitioning patient requests.
Clinicians consistently send medical records to adult
providers for their transitioning patients.
The practice sends a transfer package that includes the
plan of care (including the latest transition readiness
assessment, transition goals/actions, medical summary
and emergency care plan, and, if needed, legal
documents, and a condition fact sheet).
The practice sends a complete transfer package (including
the latest transition readiness assessment, transition
goals/actions, medical summary and emergency care
plan, and, if needed, legal documents, and a condition
fact sheet), and pediatric clinicians communicate with
adult clinicians, confirming pediatric provider’s
responsibility for care until young adult is seen in the
adult practice.
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#6: Transfer Completion
 Level 1:
 Level 2:
 Level 3:
 Level 4:
Clinicians have no formal process for follow-up with
patients who have transferred to new adult providers.
Clinicians encourage patients to let them know
whether or not the transfer to new adult provider
went smoothly.
The pediatric practice communicates with the adult
practice confirming completion of transfer/first
appointment and offering consultation assistance, if
needed.
The practice confirms transfer completion, need for
consultation assistance, and elicits feedback from
patients regarding the transition experience.
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Second Measurement Option
Health Care Transition Process Measurement Tool
• Objective scoring method with documentation
requirements
• Measures implementation of Six Core Elements,
consumer feedback and leadership, and
dissemination
• Intended to be conducted at start of QI initiative as
baseline measure and repeated to assess progress
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Measurement Tool: Policy Example
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Summary of Latest Developments in
Clinical and Measurement Tools
• Six Core Elements (2.0)– Side by Side Handout
• 3 different packages – for patients leaving pediatric
care, staying with their same provider, and entering
adult care
• Tools can be customized for your practice
• Available measurement tools – qualitative and
scorable options and a consumer feedback survey
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What to do?
Where to start?
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STARTING TRANSITION QI/PILOT IN
PRIMARY, SPECIALTY, AND MANAGED CARE






Involve pediatric and adult practices, NOT pediatric only
Gain leadership buy-in
Involve parent, youth, and YA consumers
Start as pilot using QI methods
Measure progress
Adapt and spread
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A Primary Care Example: DC
• Five large pediatric and adult academic primary care sites: Children’s
National Medical Center’s adolescent clinic, CNMC’s Adams Morgan Clinic
(mostly Latino), Georgetown’s adolescent clinic, Howard’s family medicine
clinic, and GW’s internal medicine clinic
• Teams: lead physician, nurse/social worker care coordinator, and consumer
• Transition population: Medicaid-insured youth with special health care
needs (all SSI-eligible and majority African American)
• 5 one and half day learning sessions plus regular coaching calls and on-site
visits over 22 months (Feb. 2011-Dec. 2012)
• Use of QI methods/PDSA cycles
• Got Transition staff provided coaching
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Results from DC Transition Learning
Collaborative
• All pediatric, family medicine, and internal medicine practices
created practice-wide policies on transition
• A total of 400 youth and young adults included in pediatric
transition registries and 128 in adult registries
• Transition readiness assessments conducted with patients in
their registry: 88% in pediatric sites and 73% in adult sites
• Transition plans developed: 29% of youth and 32% of young
adults
• 50 youth and young adults transferred to adult practices
during last 6 months of LC -- with updated medical summary,
transition readiness assessment, and a plan of care
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DC LC Pediatric and Adult Practices
HCT Index Data
Average total score for each core element
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Lessons Learned From DC LC
• Feasible to implement Six Core Elements with ready made adaptable tools
• Involvement of pediatric, family medicine, and adult practices from outset
was key
• Senior leadership (practice and department) engagement essential
• Transition planning in early adolescence is much easier than transition
planning at ages 18 and older
• Involvement of nursing, social work, and other clinic staff who are part of
clinic processes is critical
• Engagement of consumers is important and challenging to maintain
• Sustainability requires EHR integration and payment mechanisms- both are
currently being actively addressed by Got Transition
• A variety of care transfer models evolved depending on the availability of
adult subspecialty care for specific pediatric-onset diseases
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A Subspecialty Transition Example: U.
Rochester (NY)
• Department of Pediatrics identified transition as a top issue
across all subspecialty divisions
• Chair appointed “transition task force” to facilitate this
process, led by Dr. Brett Robbins
– Centered in division of adolescent medicine
– Strong representation of combined Med-Peds trained faculty
• Key stakeholders identified for committee
– Enlisted the support of the Chair of Medicine
– Access to division chief meetings in both IM and Peds
– Chose 6 core elements as template for QI process
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Subspecialty Transition
• Pediatric and Internal Medicine divisions initially
completed a baseline Current Assessment of Health
Care Transition Activities
• Selected 3 pediatric-medicine subspecialty dyads
based on interest and disease process
– Endocrine (DM), Hematology (SS) , pulmonary (CF)
– All 6 completed a baseline HCT Process Measurement Tool
– All 6 selected 1-2 representatives (MD, SW, NP)
• Monthly Meetings between ped and im division reps
• QI process with many PDSA cycles
• Goal of incorporating 6 core elements into process
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Themes at Start-up
• Completing Current Assessment of HCT at start was
itself an intervention
• Low level of explicit transition policies and transition
practices
• Peds: not energetic about process
• IM: Confused but willing
• Neither involving patients and families
• Neither “knew what they didn’t know” about the
transition process
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Subspecialty Transition
Lessons Learned
• Low level of baseline transition work or even awareness among all IM and
Peds subspecialties
• Most work in QI process done by SW, NP
• Peds had many misperceptions of IM
• Peds had a very hard time letting go
• IM not prepared, but eager to learn
• Sometimes hard to find willing IM provider
• Need buy-in from chairs and division chiefs
• Need lots of IT support, but don’t get lost in the computers
• Moderator with credibility in both departments is very helpful
• Policies and assessments come far easier than trust and implementation
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A Medicaid Managed Care Example:
DC
• Why are health plans interested in pediatric to
adult transition?
– Ensure continuity of care and improve self-care,
particularly among those with chronic conditions
– Retain young adults as health plan members
– Improve satisfaction among young adults (often among the
most dissatisfied health care consumers)
– Comply with PCMH certification standards
– Reduce unnecessary ED visits/hospitalization
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Health Services for Children with
Special Needs (HSCSN): A DC MCO
• Serves 6,000 Medicaid enrollees from birth to age
26, all with SSI-eligible conditions
• Analysis of HSCSN utilization data revealed:
– A sizeable proportion of young adults over age 22 still being seen by
pediatric providers.
– Approximately two-thirds of 18-21 year olds with chronic conditions
cared for by pediatric PCPs and will need to transfer to adult care in
the next few years.
– A large proportion of young adults are not using primary care,
especially those with developmental disabilities, but using ER
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Service Utilization Profile of HSCSN
Members, Ages 18-26, in 2013
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Pilot Transition Intervention
• Several senior leadership meetings to gain buy-in and health plan context
(eg, ongoing care planning, QI processes, insurance transition planning)
• Series of meetings with senior nurse care management staff to review and
customize each core element and obtain final review by medical director
and CEO
• Next piloted the customized 6 core elements with small group of enrollees
and pediatric and adult practices
• Defined roles of HSCSN, provider practices, and Got Transition
• Designation of single nurse care manager and AmeriCorps volunteer to
implement pilot project within health plan
• Invitation and education of pediatric and adult practices (lunch & learn)
• Invitation and active outreach to engage young adults
• Weekly updating, transition mentoring, and trouble-shooting calls with
HSCSN and Dr. White (Got Transition)
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Customized Six Core Elements
• Health care transition policy (customized)
• Tracking spreadsheet (customized)
• Readiness assessment (customized)
– Insurance question added
• Integrated transition plan (customized)
• Plan of care (customized)
• Medical summary and emergency care plan
• Transfer checklist
• Welcome & orientation of new young adult
• Feedback survey (for young adult & family/caregiver)
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HSCSN Pilot Project
• 49 HSCSN members
– ages 18-25
– SSI-eligible diagnostic groups: mental health,
intellectual/developmental disability, and complex medical
– 35 agreed to participate; 14 members discontinued
participating
– Range of case management complexity levels
• Practices: 3 pediatric and 1 adult site in DC
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Key Results of Transition Pilot
• Over 80% of pilot group received recommended 6 core
elements in 6 months
• Based on readiness assessment results, only 50% of YAs knew
their medical needs, could explain these needs to others, and
knew about privacy changes at age 18. Almost 80% reported
needing to learn to call for their own doctor visits
• Completion of transfer among those 18 and older was very
difficult, primarily because of problems engaging YA
• Using Got Transition’s Current Assessment of HCT: HSCSN
scored at level 1 at start; 6 months later: level 3 for each core
element. To get to level 4, spread is required.
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Lessons Learned
• The Six Core Elements can be implemented/customized into a managed
care plan’s processes
• Transition process should begin before age 18, preferably around ages 1214, while the youth and family are regularly using health services and
engaged in their health
• Important to delineate roles of managed care staff and pediatric and adult
health care providers, but SHARED role preferred by clinicians
• Need for plan to proactively identify adult PCPs willing to treat young
adults with mental health, ID/DD, and complex medical conditions;
communicate these PCP choices to young adult members; and encourage
adult practices to provide welcome information for their new young adult
members
• Managed care plans need to consider using financial incentives to gain
more traction
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Summary of Primary, Specialty, and
Managed Care Transition QI Examples
• Feasible to adapt and implement Six Core Elements in
primary, specialty and managed care
• Starting as a pilot important
• Involvement of pediatric and adult leadership and teams is
key
• Everyone is at the same starting point- Level 1
• Implementation takes more than writing a policy and doing a
readiness assessment
• Progress is rewarding and sustainable
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Payment for Transition
• See handout, Coding and Reimbursement Tip
Sheet for Transition
• Developed by Got Transition with the AAP
• Describes a set of innovative payment
strategies
• Provides a comprehensive list of CPT codes
and Medicare values
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Options for Enhanced Fee-For-Service
Payments
• Reimburse at higher fees – eg, for office visits
before and after transfer
• Recognize codes previously not paid for -- eg, care
plan oversight, telephone calls
• Even if providers don’t recognize these codes, it is
still important to code for the service
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Options for Pay for Performance
• Tie bonuses for pediatric and adult provider transition efforts
together. For example,
– Transfer before age 22 with current medical information
and evidence of communication with adult providers + first
adult PCP visit within 6 months of last pediatric visit and
evidence of orientation/welcome to new young adult
• Offer bonus to adult providers for taking certain volume of
young adults with chronic conditions
• Tie P4P to improvements made or scores received on Got
Transition measurement tools
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Options for Capitation
• Offer monthly care coordination payments to
added time:
– in preparing youth/family for transfer,
– preparing the necessary transfer documents,
– ensuring coordination and communication
between pediatric and adult systems, and
– implementing outreach and follow-up strategies
for new young adult patients
• Consider adjusting for complexity of patients
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Options for Bundled Payments
• Package of transfer and new patient services:
– Face to face visits
– Updating medical summary, readiness assessment, plan of
care
– Communication between providers
– Assessment of treatment and medication of new patients
– Identification of adult specialists
• CPT code for transitional care management services only for
hospital to home/community settings
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Option for Shared Savings
• Savings from reduced emergency room and
hospitalization could be shared with
participating pediatric and adult providers
• Structural and quality standards from Got
Transition could be used
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Options for Administrative or
Infrastructure Payments
• Options used in Medicare (EHR) and Medicaid
(to implement state Medicaid plan)
• Could be used to customize EHR to
incorporate 6 core elements
• Or for transition training of pediatric and adult
providers
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Summary of Payment Options
• Many options available to serve as financial
incentives
• Just need to get the payers to the table
• Got Transition, in near future, will put out a
crosswalk for billing for Six Core Elements
• We are also reaching out to Medicaid MCOs and
commercial health plans to inform them of Six Core
Elements and to encourage their payment support
for transition delivery improvements
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Youth and Family Resources
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Presentation Learning Objectives
1. Understand latest developments in clinical and measurement
tools for transition from pediatric to adult health care.
2. Review examples of QI strategies to incorporate transition
core elements into 3 types of practices/systems: academic
primary care settings, academic subspecialty clinics, and a
Medicaid managed care plan.
3. Identify innovative payment strategies for transition.
4. Learn about new health care transition resources for youth
and families.
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Thank You and Questions
MMcManus@thenationalalliance.org
Please visit
www.GotTransition.org
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