Innovations in Pediatric to Adult Health
Care for Clinicians and Health Systems
SCTR Scientific Retreat
February 8, 2016
Patience H White, MD, MA, FAAP, FACP
Got Transition/Center for Health Care
Transition Improvement
Professor of Medicine and Pediatrics
George Washington University School of
Medicine and Health Sciences
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Disclosures
• I have no commercial relationships to disclose.
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Presentation Learning Objectives
1. Identify the national case for pediatric to adult
health care transition (HCT) improvements
2. Review the 6 core elements and tools for
implementing the AAP/ACP/AAFP HCT Clinical Report
3. Discuss how to start a HCT quality improvement
process
4. Review lessons learned from implementing HCT
process from integrated delivery systems
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Health Care 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. Disseminate Health Care transition quality
improvements
2. Provide education/training to health professionals
3. Expand youth/young adult and family engagement
4. Improve transition policy
5. 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
• Surveys of health care providers consistently show they lack a systematic way
to support youth, families, and young adults in transition
Costs are increased:
• Increased ER, hospital use, and duplicative tests result
*Prior et. al. Pediatrics 134:1213 2014
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National Context for Transition
•
US youth 18 years of age
•
•
There are est 4.5 million youth 18 years of age in the US*; 25% 12-17
year olds have a SHCN**, thus each year an est 1 million youth with
SHCN will need transition support.
National Organizations supporting transition
•
•
•
•
•
ACA: Transition an essential health home service, insurance
expansions for young adults
NCQA medical home standards on transition
(plan of care, self-care support, transfer of
medical records)
Healthy People 2020 (discussion of transition planning with health
care provider)
Bureau of Maternal Child Health has transition as one of 13 national
priorities
CMS/CMMI focus on transition from hospital
to home
* 2010 Census **2011/2012 National Survey of Children's Health
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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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California High Speed Rail Authority (Public Domain)
State of Health Care Transition from
Pediatric to Adult Health Care Approaches
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NOAA Historic Coast & Geodetic Survey Collection (Public Domain)
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 with set of
sample tools and transition index.
• HCT Learning Collaboratives (with primary and specialty care
practices)
– Conducted between 2010-2012 in DC, Boston, Denver, New
Hampshire, Minnesota, Wisconsin
– Used well-tested Learning Collaborative methodology from
the National Initiative for Children’s Healthcare Quality and
pioneered by Institute for Healthcare Improvement
– Demonstrated Six Core Elements and tools feasible to use in
clinical settings and resulted in quality improvements in
transition process*
* McManus et al. Journal of Adol Health 56:73 2014
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Updated Version of Six Core Element Tools
 Published in 2014
 Based on learning collaboratives in DC, MA, NH, WI, MN
 Reviewed by over 100 clinical (primary and subspecialty
providers, nurses, nurse practitioners, PAs and social workers)
and consumer experts
 Represents state-of-the-art (process and tools)
 New Six Core Elements have three packages with expanded
measurement options and tools for core element and can be
used by all members of the health care team.
 5th grade reading level, Spanish translation available
 CUSTOMIZABLE, USE YOUR OWN LOGOS
 FREE (download from www.gottransition.org)
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Six Core Element Approach to Health Care
Transition
• Discuss Transition
Policy
AGES 14-15-1617-18
• Assess skills
• Track progress
AGES 14-15-1617-18
• Develop transition plan,
including medical
summary
AGES 14-15-1617-18
AGE 12-14
• Transfer to adult –
centered care
• Integration into adult
practice
AGES 18-26
• Confirm transfer
completion
• Elicit consumer
feedback
• Ongoing Care
AGES 18-21
1
2
3
4
5
6
Transition
Policy
Transition
Tracking
and
Monitoring
Transition
Readiness
Transition
Planning
Transfer/
Integration
into AdultCentered
Care
Transition
Completion/
Ongoing
Care
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Six Core Elements 2.0
(See Side-by-Side Handout)
Today I will offer mainly examples of tools from the “transitioning youth to
an adult provider” package
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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CORE ELEMENT #1: POLICY
• Purpose: Formalize practice’s approach, reduce clinician
variability and offer a transparent approach to youth and
families
• Content:
– Define practice approach and recommended ages for
transition preparation for adult-focused care, transfer,
and integration into adult care
– Clarify adult approach to care and legal changes at
age 18
– Reading level should be appropriate
• Post: Communicate it to all involved early in the process
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Element 1. Transition Policy
• Make larger
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Core Element #2: Transition Tracking and Monitoring
• Purpose: Facilitate systematic data collection to
improve quality at individual and population levels
• Content:
– Demographic and diagnostic/complexity data
– Date of receipt of each core element (eg, policy
shared, readiness assessment administered, etc.)
• Format: paper check list, excel spread sheet, EHR
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DE
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Core Element #3: Transition Readiness
(Pediatric practice example)
• Purpose: assess the youth’s skills to manage their
health/health care in the adult approach to care and (selfcare skills assessment available in adult package)
• Content:
• Ranks importance of changing to adult provider before age 22
• Ranks confidence about ability of changing to adult provider
• Assesses self-care skills related to own health and using health
care services
• Use:
•
•
•
•
Completed several times during the transition process
Used as a discussion tool to plan skill building education
Does not predict transition success
Customized to meet the needs of the practice’s population
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Core Element #3: Orientation to Adult Practice
(Adult Practice Example)
Purpose: Establish a process to welcome and orient
new young adult patients into practice
Content:
• Identify adult providers in practice interested in caring
for young adults
• Acknowledge young adults as a distinct patient
population
• Clarify privacy, consent, and shared decision-making
• Describe patient responsibilities
• Describe services, hours, insurance info, costs (Share
welcome letter/ adult office policy)
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Core Element #4: Transition Planning
(Pediatric Practice Example)
• Purpose: Establish agreement between youth and provider
about set of actions to address priorities and access current
medical information
• Content:
– Identify what matters most to youth in becoming adult
beyond health goals
– Define how learning about health and health care supports
youth’s over all goals (add readiness assessment skill needs
to the plan)
• Complete portable medical summary and emergency care
plan with “special information” for adult provider
– Include non medical information that the youth and family want to
share and will assist the adult provider to engage the youth easily
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Facilitate Youth Knowledge of their
Health Information
• Majority of youth/young adults have a cell phone
• Add health information to their phone (diagnosis,
allergies, medications, who to contact in an
emergency) ideally before the phone needs to be
unlocked so EMS has access to it
• Facilitates their ability to communicate key health
information when needed
• iPhone example: utilize Health App
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Core Element #4: Integration into Adult Practice
(Adult Practice Example)
• Purpose: Establish systematic process for coordinating
transfer with pediatric practice and obtaining current medical
information
• Content:
– Communicate with pediatric provider and arrange
consultation, if needed
– Ensure receipt of transfer package and condition fact
sheet, if needed
– Office could make pre-visit reminder call and ask if special
accommodations are needed
– Identify community resources (eg. Decision support,
support groups, insurance information)
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Core Element #5: Transfer of Care
(Pediatric Practice Example)
• Purpose: Ensure completion and sharing of transfer
package with adult provider and support engagement of
young adult with a new provider
• Content:
– Transfer letter, clarifying coverage of youth’s care until
initial adult visit with transfer package
– Communicate directly with the adult provider, send
transfer package with the last readiness assessment,
plan of care, medical summary and emergency care
plan, condition fact sheet, guardianship doc., and offer
consultation.
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Core Element #5: Initial Adult Visit
(Adult Practice Example)
• Purpose: Ensure a personalized, efficient, and consistent
initial visit
• Content:
– Review of transfer package prior to visit
– Address young adult’s concerns about confidentiality, and
transfer, clarify adult approach to care and access to
information, and preferred methods of communication
– Discuss young adult’s health priorities as part of plan of
care, review transition readiness assessment and/or
complete self-care assessment, and update medical
summary, emergency care plan and phone app
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Core Element #6: Transfer Completion
(Pediatric Package Example)
• Purpose: Confirms initiation of the new adult
provider and the ending of pediatric role, except as
consultant
• Content:
– Communicate with adult practice confirming
completion of transfer
– Obtain consumer feedback anonymously after last
pediatric visit (example feedback form at
gottransition.org)
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Core Element #6: Ongoing Adult Care
(Adult Practice Example)
• Purpose: Ensure continuity of care and
ongoing care management
• Content:
– Confirm with pediatric provider transfer of care
responsibilities and obtain consultation, as needed
– Identify needed adult specialists and assist with referrals
to community resources
– Provide ongoing care and periodically assessing self care
skills
– Elicit consumer feedback anonymously
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Photo by Ovidiu Maris
Used under Creative Commons License (CC BY-NC 2.0)
Measurement Options
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Measurement Options
1
Initial Health Care Transition Assessment
• Qualitative self-assessment tool modeled after
index
• Provides a snapshot of where practice initially
is in implementing transition processes
• Questions on consumer feedback and
leadership
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Core Element #1: Policy
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Measurement Options
2
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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What to do? Where to start?
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Photo: Jon Candy (CC BY-SA 2.0)
Integrated Care Systems collaborating with Got
Transition on HCT QI
Cleveland Clinics
Primary Care
Henry Ford Health System
(MI)
Primary Care
University of Rochester
Specialty Care
Walter Reed National
Military Medical Center (MD)
Specialty Care
DC Managed Care
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 Partnership in implementing
and evaluating new Six Core
Elements packages
 Pediatric and adult provider
(includes Med-Peds and Family
Medicine) teams participating
 Coaching support to networks
by Got Transition
 Goal: to learn about
dissemination of transition QI
and ROI
Starting a Transition Improvement Process
(see available tip sheet at gottransition.org)
• Developed with integrated health care systems
implementing HCT QI with Six Core Elements
• Steps to maximize success
– Step 1: Secure senior leadership support
– Step 2: Form transition improvement team
eg both pediatric and adult providers/IT/payers/consumers
– Step 3: Define transition processes for improvement
eg. Articulate scope, population, strategies, time line, measures of success
– Step 4: Dedicate time to implement transition improvements
eg. This is hard work that takes dedicated time and leadership
– Plus additional Tips for Success
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A Subspecialty Transition Example:
U. of 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 that helped initiate the
focus on HCT
• 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 clinical care process
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Subspecialty Transition
Lessons Learned
• Low level of baseline transition work or even awareness
• Must have buy-in from Leadership chairs and division chiefs
• Choose your pilot projects wisely, the rest of the system is
watching
• Most of day to day work in QI process done by SW, NP
• Ped subspecialty had many misperceptions of IM
• Peds had a very hard time letting go
• IM not prepared to care for YA, but eager to learn
• Need 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-next steps QI process for PC ACO
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Henry Ford Health System HCT Initiative
Primary Care Example
• Leadership engagement (started 18 months ago)
– HCT focus provided HFHS a mechanism to support the shift
in physician RVU targets to panel size targets-incentive to
keep patients within the HFHS system
• Pilot HCT Team
– 4 PC practice sites (2 pediatric & 2 IM)
– Completed Current Assessment HCT Activities at each site
– Physicians, nurse supervisors, pediatrics administrator,
patient partner, administrative fellow
– Meet by phone monthly
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Henry Ford Health System HCT Initiative
• Started with Healthcare Transition Webinar for
pilot Team
• Define goals/outcomes/timelines
– HCT Policies created in Pediatrics, Internal
Medicine and Family Medicine
– Defined pilot population
– Focused on the “low hanging fruit” for HCT
process change (starting with older youth within
peds, etc)
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Henry Ford Health System HCT Initiative
• Utilize EMR After visit summary to disseminate HCT
Policy
 PDSA cycles
 Feedback from providers, patients,& parent
• MyChart Healthcare Skills Questionnaire
 customized and piloted
• Next Steps:
 Developing Epic plan of care
 Survey of all HFHS adult providers on willingness to care for
young adults with and without SHCN for future transfers,
directory and welcome letters
 Stream line adult medicine primary care Epic referral process
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Current Assessment of Henry Ford
Health System HCT Initiative
Core Element
Pediatric CAHCTA Level
Initial/12 months
Adult CAHCTA Level
Initial/12 months
Policy
1/3
1/3
Tracking
1/1
1/1
Readiness
1/3
1/1
Planning
1/2
1/1
Transfer
1/1
1/2
Completion
1/1
1/1
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Lessons Learned
• HCT fit into a larger strategic issue for HFHS
• Motivation and the perceived need for structured HCT
approach (tools and processes) differs between pediatric and
adult providers:
– Pediatrics leads initial work on HCT activities-understand
need/urgency for HCT
– Most adult providers less engaged in young adult care/find
and focus on those interested from the beginning
• Engaging the patient is a fundamental strategy for persuading
reluctant team members
• Perfection is the enemy of good, practice change is hard
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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
• GT Analysis of HSCSN utilization data revealed:
– A sizeable proportion of young adults over age 22 still being listed as
being seen by pediatric providers.
– Approximately two-thirds of 18-21 year olds with chronic conditions in
the health plan and on the panels of pediatric PCPs will need to
transfer to adult care in the next few years (before the age of 26).
– A large proportion of young adults are not using their PCP, especially
those with developmental disabilities, but using ER
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Pilot Transition Intervention
• Several senior leadership meetings to gain buy-in and health plan context
• Meetings with senior nurse care management staff to review and
customize each core element tool
• Defined roles of HSCSN care managers, adult and pediatric provider
practices
• 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
• Piloted the customized 6 core element tools with small group of enrollees
and pediatric and adult practices
• Weekly updating, transition mentoring, and trouble-shooting calls with
HSCSN and Got Transition staff throughout the project
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• WHO:
HSCSN Pilot Project
– 35 HSCSN members (ages 18-25, SSI-eligible diagnostic groups: mental
health, intellectual/developmental disability, and complex medical, Range of
case management complexity levels) Practices: 3 pediatric and 1 adult
site in DC
• Results*:
– 80% received 6 core elements in 6 months, 50% knew their medical needs,
knew about privacy changes at age 18 and 80% reported needing to learn to
call for their own doctor visits
– Transfer of those 18 and older was difficult, primarily because YA not
engaged in pediatric HC so out reach role of care manager was key
– Using Got Transition’s Current Assessment of HCT: HSCSN plan scored at
level 1 at start; 6 months later: level 3 for each core element. To get to level
4, dissemination would be required(next step).
*McManus et al: JAHM 2015
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Lessons Learned
• The Six Core Elements can be implemented/customized into a managed
care plan’s processes and facilitates transition for their members
• Transition process should begin before age 18, preferably around ages 1214, while the youth and family are regularly using their pediatric health
services and engaged in their health
• Young Adults hard to engage in health and going to an adult health care
provider
• Important to delineate roles of managed care staff and pediatric and adult
health care providers, but SHARED role preferred by clinicians
• Health Plan needs 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 among providers
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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 with a pilot is important to test the processes before
dissemination throughout the system
• Engagement of system leadership and involvement of pediatric and adult
provider leadership with broad based teams including consumers is key
• Outline outcome and evaluation strategies upfront, plan the QI process so
everyone is on board and knows what success looks like
• Everyone is at the same starting point- Level 1 of the GT Measurement
tool
• Practice change takes time; HCT implementation takes more than writing
a policy, doing a readiness assessment or putting tools into the EMR
• Progress is rewarding and sustainable
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Payment for Transition
• Code 99240 now can be billed when a
readiness assessment/self care assessment is
completed by the youth.
• See 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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Want more information?
Got Transition: Federally funded resource center on HCT
www.gottransition.org
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Thank You and Questions
pwhite@thenationalalliance.org
HealthCareTransition
@GotTransition2
Visit www.GotTransition.org
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