GHC Transition Project

Youth Health Transition Initiative Ann Behrmann, MD

Mala Mathur, MD, MPHFebruary 10, 2014

History of Pediatric Medical Home Pilot Projects at GHC 2004-2014

• Comprehensive Care Plans (CCP) in EMR: Office Workflows to develop and update CCP with original medical home team (care management RN, team RN, MD, parent advocate, Waisman Southern Regional Center for CYSHCN)

• Developmental Screening Project—incorporated ASQ, into all 9,18,24 and 36 mo WCC and MCHAT into visits with tracking

• Kids Medical Home website (http://duff-co.com/KMH )• Transitions Project

Why a transitions project?

• Primary Care transitions from pediatric to adult care are happening but currently there is no organized procedure resulting in a lack of parent/patient education about this process.

• Healthy People 2020 includes improving the healthy development, health, safety, and well-being of adolescents and young adults.

• New NCQA requirements include components of transition process from pediatric to adult healthcare

GHC Transition Project 2012-2014

• Worked closely with national partners “Got Transition” and with state partners “Wisconsin Youth Health Transition Initiative” to understand latest guidelines and to get support with already developed resources/tools.

• Done as an ABP MOC project (25 credits) with Got Transition team and WI state partners

• Pilot Project using Transition Checklists Fall 2012-Summer 2013• Presented findings from GHC’s Pilot Project at “14th Conference on

Disability and Chronic Illness: Transition from Pediatric to Adult based Care” at Baylor October 2013

Pilot Project Fall 2012-Summer 2013

• Developed Policy Statement on Transition for our organization• Gave out Transition Checklist to all adolescents age 12-22—at

both sick and well visits• Used Checklist as a springboard for discussion about the

transition process• Initiated separate transition visits for a handful of our YSCHN• Worked on developing patient education materials for teens and

parents• Worked on Smart Text (and specific AVS info) for transition

Methods• Checklists given to all youth (healthy and YSHCN)

age 14-22 for both well and acute care visits over a 14 month period (July 2012-September 2013)

• YSCHN defined in this study as youth with chronic medical conditions that impact their functioning and require care above a typical healthy adolescent

• Checklists given to parent if present with youth for office visit

Total number of youth participants = 92Total number of family participants = 63

Methods Checklists given to all youth (healthy

and YSHCN) age 14-22 for both well and acute care visits over a 14 month period (July 2012-September 2013)

YSCHN defined in this study as youth with chronic medical conditions that impact their functioning and require care above a typical healthy adolescent

Checklists given to parent if present with youth for office visit

Total number of youth participants = 92

Total number of family participants = 63

Age 14-15

43%Age 16-17

37%

Age 18 +20%

Age Distribution

72%

26%

51%

16%

Checklist ParticipationYouth:Healthy Youth:YSHCN

Family:Healthy Family:YSHCN

n=26n=48

n=15

n=66

Results of Pilot Project

• Transition Checklists were confusing as kids of all ages were given the same checklist and verbiage was unclear at times

• Most families were very interested in finding out what they could do to help prepare their child for the changes they face when accessing health care as an adult

• Patient education materials were needed to help support what verbal patient education was being given by provider

• Realized need to involve multiple GHCSCW departments: Quality Improvement , Information Technology, Compliance Officers, Marketing, Nursing Supervisor in process development

Tangibles from Transition Work

• Revised Checklists that are broken down by age group (age 12-14, age 15-17, age 18 and up)

• “Tool Kit for Teens”-patient educational handout• “Health Care Transition in Adolescence”- parent educational

handout• Transitions Policy and Procedure for GHC (draft)• Transition Introductory Letter to parents (draft)

GHC Transition Timeline for all kids

Age 12-14Transition Checklist; Toolkit for teens and

Parent Handout

Age 15-17 Transition Checklist

Patient Education/Handouts

Age 18-22 Transition ChecklistPatient Education

GHC Transition Timeline for YSHCN

Age 12Transition Checklist;

Update CCP; Toolkit for Teens and Parent

Handouts; Behavioral Health

Age 14-17 Transition Checklist

Toolkit for Teens and Parent Handout

Transition Packet for Parents of YSHCN

(Waisman)Update Comprehensive

Care Plan (CCP);Behavioral

Health/Social Work

Age 18-21 Transition ChecklistTransition Packet for

YSHCN (Waisman)Community trainings

and resources for youth and family (advance directive, power of

attorney, legal issues, school, employment); Behavioral Health and

Social Work

Policy to Procedure

• Need to develop workflow procedure for CNA, LPN, RN, Provider—this being done by our team RN and Care Management RNs

• For separate transition visits for YSHCN, need to consider pre-visit prep: possibly as 30 min RN/30 min provider visits or other supported workflow

• Can code for transition work (phone care coordination and visits)

Barriers to Workflow

• Education for providers/staff about importance of transition• Need to develop Patient Registry for Transition in YSHCN

population in EMR which is accessible and editable• Time for RN to do pre-visit prep and for provider to update CCP

and problem list regularly at least every 6 months(problem based charting may help in future)

Barriers to Workflow Continued…

• Time constraints for developing good communication between pediatric MD and FP or IM provider who will assume care of young adult

• Time constraints for joint visits with patient and both MDs (peds and adult provider) to review problem list, medications, PE issues

• Incorporating Care Management, Social Work, Behavioral Health into Transition Process

• EMR: Working on getting checklists into flow sheet and adding patient education materials to AVS and possible BPA to help populate problem list (allow for outcome measurements)

Transition and EPIC

• Currently:– Smart Set with Smart Text on transition drafted in 2013

• Future:– Working on getting patient education materials in AVS– Working on flow sheet for checklist– Working on Best Practice Alert– Working on adding smart data elements to a newly inserted question in WCC

(12-17 year) to track how many members are getting transition education and develop outcome measures to evaluate transition process –looking at both sustaining quality of care and patient, staff satisfaction

Challenges for Transition

• MyChart- need way to have confidential communication with both adolescents and parents

• Full functionality of MyChart for families of YSHCN between ages 12-17 years within HIPAA guidelines

• Identification of adult providers at GHC who will accept YSHCN• Developing a process for joint visits with YSHCN and peds and adult

MDs• Coordinated transition of UW specialty care from Pediatric to Adult

Services (for some specialties considering teen/young adult clinics that focus on self care, prevention, understanding of health issues)

Next Steps continued

• Share process with colleagues to help support all families at GHC in the transition process

• Training of staff to use checklists and providers to utilize smart sets and AVS resources

• Build and utilize means to evaluate Transition process and outcome measures to monitor usefulness to patients, GHCSCW

TRANSITIONS: From a Family Medicine Perspective

Leah Ederer, MD

Difficulties• No clear transition time

• Because of family setting we are often seeing parents as patients as well who ask questions about their children or speak for their children

• MyChart difficulties

• Messages in parents chart not “kidschart”

• Parents creating children’s e-mails

College Students

University Health Services

• Involved in the student community

• Available for help with projects

• Facebook and Twitter

• Easy to navigate and informative website http://www.uhs.wisc.edu/

• New student checklist including immunizations needed

http://www.uhs.wisc.edu/about-uhs/documents/entranceletter.pdf

College Students

• Location issues

• On parents insurance

• Can only be seen over break

• MyChart and refills over a distance

• Mental Health Issues

• Back and upper extremity injuries from computer use

Implementation

• Split appointment

• 30 min with RN for checklist and education

• 30 min with MD for questions and physical

• Similar structure already successful with pre-op and Medicare physicals.

• Checklist format already available for OB visits

Checklist format in Epic

Comments or Questions?