Transition Update - Health Transition Wisconsin

GHC Transition Project
Youth Health Transition Initiative
Ann Behrmann, MD
Mala Mathur, MD, MPH
February 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 ( )
• 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
• Initiated separate transition visits for a handful of our YSCHN
• Worked on developing patient education materials for teens and
• Worked on Smart Text (and specific AVS info) for transition
• Checklists given to all youth (healthy and YSHCN)
M e th o d s
age 14-22 for both well and acute care visits over a
 C h e ck lists g ive n to a ll yo u th (h e a lthy
14 month period (July 2012-September
a n d YS H C N ) a ge 1 4 -2 22013)
fo r b o th w e ll
a n d a cu te ca re visits o ve r a 1 4 m o n th
• YSCHN defined in this studyp eas
rio d youth
(Ju ly 2 0 1 2 -S
e p te m chronic
ber 2013)
 YS C H N dtheir
e fin e d infunctioning
th is stu d y a s yo u th
medical conditions that impact
w ith ch ro n ic m e d ica l co n d itio n s th at
im p a ct th healthy
e ir fu n ctio n inadolescent
g a n d re q u ire
and require care above a typical
A ge D istrib u tio n
ca re a b o ve a ty p ica l h e a lthy
C h e ck list Pa rticip atio n
o le sce n t
• Checklists given to parent ifa dpresent
with youth for
 C h e ck lists g ive n to p a re n t if p re se n t
office visit
w ith yo u th fo r o ffice visit
A ge 1 8 +
A ge 1 6 17
A ge 1 4 15
Y o u th :H e a lth y
Y o u th :Y S H C N
F a m ily:H e a lth y
F a m ily:Y S H C N
To ta l n u m b e r o f yo u th p a rticip a n ts = 9 2
Total number of youth participants = 92
To ta l n u m b e r o f fa m ily p a rticip a n ts = 6 3
Total number of family participants = 63
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 1214, age 15-17, age 18 and up)
• “Tool Kit for Teens”-patient educational handout
• “Health Care Transition in Adolescence”- parent educational
• Transitions Policy and Procedure for GHC (draft)
• Transition Introductory Letter to parents (draft)
GHC Transition Timeline for all kids
Age 12-14
Age 15-17
Transition Checklist;
Toolkit for teens and
Parent Handout
Transition Checklist
Age 18-22
Transition Checklist
Patient Education
GHC Transition Timeline for YSHCN
Age 12
Transition Checklist;
Update CCP; Toolkit for
Teens and Parent
Handouts; Behavioral
Age 14-17
Age 18-21
Transition Checklist
Transition Checklist
Toolkit for Teens and
Parent Handout
Transition Packet for
YSHCN (Waisman)
Transition Packet for
Parents of YSHCN
Community trainings
and resources for youth
and family (advance
directive, power of
attorney, legal issues,
school, employment);
Behavioral Health and
Social Work
Update Comprehensive
Care Plan
Health/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 previsit prep: possibly as 30 min RN/30 min provider visits or
other supported workflow
• Can code for transition work (phone care coordination and
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
• 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
• 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,
TRANSITIONS: From a Family Medicine Perspective
Leah Ederer, MD
• 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
• New student checklist including immunizations needed
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
• 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?

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