Evaluation of a Health Care Transition Improvement Process in Seven Large Health Care Systems

Adult provider role in transition of care for young adult pediatric recipients of liver transplant: An expert position statement

Health care transition (HCT) is the process of changing from a pediatric to an adult model of care. Young adult pediatric recipients of liver transplant transferring from pediatric to adult health care services are highly vulnerable and subject to poor long-term outcomes. Barriers to successful transition are multifaceted. A comprehensive HCT program should be initiated early in pediatrics and continued throughout young adulthood, even after transfer of care has been completed. It is critical that pediatric and adult liver transplant providers establish a partnership to optimize care for these patients. Adult providers must recognize the importance of HCT and the need to continue the transition process following transfer. While this continued focus on HCT is essential, current literature has primarily offered guidance for pediatric providers. This position paper outlines a framework with a sample set of tools for the implementation of a standardized, multidisciplinary approach to HCT for adult transplant providers utilizing "The Six Core Elements of HCT." To implement more effective strategies and work to improve long-term outcomes for young adult patients undergoing liver transplant, HCT must be mandated as a routine part of posttransplant care. Increased advocacy efforts with the additional backing and support of governing organizations are required to help facilitate these practices.

A Quality Improvement Initiative to Improve Health Care Transition Planning at Adolescent Well Visits

OBJECTIVE

Health care transition (HCT) planning supports adolescents as they move from pediatric to adult health care and is recommended for all youth. HCT planning uptake remains low, with little known about HCT in the adolescent well child check (WCC) setting. We sought to increase rates of HCT planning at WCCs by adapting best practices for HCT from specialty and chronic care.

METHODS

This quality improvement initiative at 12 to 17-year-old WCCs at four Internal Medicine-Pediatrics primary care clinics, was based on the first three of the "Six Core Elements" of HCT framework and integrated into the electronic health record. Two uptake measures were assessed via chart review after three plan-do-study-act (PDSA) cycles, with two provider surveys and an implementation science analysis further informing interpretation.

RESULTS

By the final PDSA cycle, the percentage of 14 to 17-year-old WCCs at which HCT planning was discussed and a screening tool completed increased from 5% to 31%, and the percentage of 12 to 13-year-old WCCs at which the HCT policy was discussed increased from 6% to 47%. Provider survey results revealed endorsement of HCT goals, but time and technological barriers, which were further elucidated in the implementation science analysis.

CONCLUSIONS

This quality improvement initiative increased rates of HCT planning during adolescent WCCs. While limited to three Core Elements and Internal Medicine-Pediatrics clinics, strengths include measures capturing all WCCs, contextualized by provider surveys and an implementation science framework. Lessons from this effort can inform future tailored HCT initiatives at adolescent WCCs.

Retention and transition to adult health care in adolescent bariatric surgery

The American Society of Metabolic and Bariatric Surgery (ASMBS) and the American Academy of Pediatrics (AAP) recommend bariatric surgery as a treatment option for severe obesity. Bariatric surgery results in weight loss and improves obesity-related comorbidities. After surgery, adolescents and young adults require close observation and interdisciplinary care to help optimize weight loss, minimize nutrient deficiencies, address mental or physical health complications, and ensure a smooth transition to adult care. Yet, the extant literature on adherence and transition of care in bariatric programs is limited. Using 3 case studies from 2 bariatric programs, one on retention and 2 on transition of care, this paper highlights learning opportunities for care delivery after bariatric surgery. A quality improvement framework and an embedded electronic medical health registry can improve retention rates within a bariatric program. In addition, implementing a workflow ensures standardization of care; however, a key challenge is inadequate staffing. The programs established a transition of care policy and protocol by incorporating several of the Six Core Elements, a recognized guide for ensuring a safe and appropriate transfer from pediatric to adult care. Several research gaps remain, and further work is needed to determine and standardize best practices for adolescent bariatric surgery.

Incorporating the Six Core Elements of Health Care Transition in Type 1 Diabetes Care for Emerging Adults

A growing body of literature finds persistent problems in the provision of recommended health care transition services, as well as adverse outcomes associated with the lack of these services in emerging adults with type 1 diabetes. The Six Core Elements of Health Care Transition offers a structured approach to the phases of health care transition support for both pediatric and adult diabetes practices. This article reviews strategies to incorporate the Six Core Elements into ambulatory diabetes care to support successful health care transition for emerging adults with type 1 diabetes.

Outcomes of a Structured Ambulatory Care Health Care Transition Approach in a Large Children's Hospital

PURPOSE

Without a structured health-care transition (HCT) process, youths with chronic conditions face increased morbidity, care gaps, and dissatisfaction. This article documents the process and outcomes of implementing a standardized approach in a large children's hospital.

METHODS

Children's Mercy Kansas City adopted Got Transition's Six Core Elements of Health Care Transition and established a system-wide implementation plan, between 2015 and 2019, involving leadership buy-in, consumer engagement, infrastructure improvements, and quality improvement efforts. Outcomes measured included the number of youths aged 12-21 years receiving transition readiness assessments and participating in goal setting, receiving counseling, and receiving a transfer order, if appropriate. Also, Division-specific process outcome surveys were conducted annually using Got Transition's Current Assessment of HCT Activities.

RESULTS

A total of 8,099 unique patients received a structured HCT intervention using the Six Core Element approach over the 5-year period. From 2015 to 2019 the average annual growth was: 207% for completion of transition readiness and goals assessments, 243% for charting of HCT discussions, and 105% for transfer orders. In 2015, 3/20 (15%) divisions were implementing this HCT intervention; in 2019, 17/20 (85%) divisions were implementing it, representing a 467% growth. Division participation in measuring HCT implementation also increased by 89% from 9/20 in 2016 to 17/20 in 2019. The average Current Assessment of HCT Activities scores increased by 35% from 14.55/32 to 19.67/32 during that time.

DISCUSSION

This hospital-wide program demonstrates that a standardized HCT process can be successfully implemented in a diverse group of outpatient pediatric primary and subspecialty care settings.

Clinics dedicated to transition preparation for adolescents and young adults with chronic conditions: Factors influencing their use

To pool resources and reduce inequalities in access to transition preparation for patients, transition clinics were created in France. They are places in hospitals, independent of the usual care departments, offering multiple resources and services for adolescents and their parents. Of the 24 physicians from care departments who were surveyed, half of them do not use transition clinics. The implementation of transition clinics in hospitals did not lead to their adoption by the care departments that needed the most support for transition preparation of their patients. A strategy improving adoption is needed to allow transition clinics to reduce inequalities.

The experiences of adolescent solid organ transplantation recipients, parents, and healthcare professionals in healthcare transition: A qualitative systematic review

PROBLEM

The transition from paediatric-centred to adult healthcare services in adolescent solid organ transplantation recipients is a period of increased risk and vulnerability, the issues related to healthcare transition have become key concerns to the healthcare community.

ELIGIBILITY CRITERIA

Qualitative studies of any design and qualitative components of mixed method studies that explored the experiences of healthcare transition among adolescent solid organ transplant recipients, parents, and healthcare professionals were included.

SAMPLE

Nine articles were finalised and included in the review.

METHODS

A systematic review of qualitative studies was conducted. Databases searched were Scopus, PsycINFO, EMBASE, Web of Science, PubMed, CINAHL and ProQuest Dissertations and Theses. Studies published between the inception of respective database and December 2022 inclusive were considered. A three-step inductive thematic synthesis method outlined by Thomas and Harden was used to form descriptive themes and the 10-item Joanna Briggs Institute Critical Appraisal Checklist was utilised to appraise the quality of included articles.

RESULTS

Two hundred and twenty studies were screened, and 9 studies published between 2013 and 2022 were included. Five analytical themes were generated: 'the struggle of being an adolescent with a transplant'; 'perceptions of transition'; 'the role of parents'; 'lack of transition readiness' and 'the need for better support'.

CONCLUSIONS

Adolescent solid organ transplant recipients, parents, and healthcare professionals faced multiple challenges in the healthcare transition.

IMPLICATIONS

Future interventions and health policies should provide targeted intervention strategies that address the barriers present in the healthcare transition to facilitate the optimization of the youth healthcare transition.

Development, pilot implementation, and preliminary assessment of a transition process for youth living with HIV

PURPOSE

To describe the development and pilot implementation of a transition process for youth living with human immunodeficiency virus (HIV) and to assess the perceptions of the process among youth living with HIV (YLHIV), their caregivers, and clinical staff.

DESIGN AND METHODS

A multidisciplinary core planning team developed a transition planning framework and process. With the assistance of the appropriate hospital departments, we created educational material for patients and caregivers and a flowsheet for documentation in the electronic medical record (EMR). Staff were trained on implementation of the process and documentation in the EMR. To assess the process, we surveyed staff, YLHIV, and caregivers for feedback.

RESULTS

Our transition process was informed by our goal to provide transition support that could respond to a variety of patient factors. We developed a process focused on four stages: 1. Introduction to Transition, 2. Building Knowledge and Skills, 3. Growing in Independence, and 4. Adult Care Ready. Each stage contains competencies for the patient and tasks for the care team. The pace of proceeding through the stages is determined by completion of competencies rather than patient age. Results from youth and staff showed that the transition process and informational material were helpful.

CONCLUSION

We developed a transition process for YLHIV and implemented this process in an HIV clinic. Initial survey data shows that youth, caregivers, and staff found this strategy helpful.

PRACTICE IMPLICATIONS

This pilot process may serve as a source of guidance to other clinics seeking to establish their own transition process.

Co-designed healthcare transition interventions for adolescents and young adults with chronic conditions: a scoping review

PURPOSE

To determine the scope of published literature on healthcare transition (HCT) interventions that have been co-designed with adolescents and young adults with chronic conditions, and to undertake feasibility assessments.

METHODS

Using Scopus, CINAHL, Medline-Ovid, Cochrane and PsycINFO databases, publications that included a HCT intervention to support paediatric to adult healthcare transition were included. Study location, design, population, description of the intervention, co-design methods, feasibility evidenced using Bowen and colleagues' framework, and outcome measures were extracted for review.

RESULTS

A total of 21 studies were included, relating to 17 co-designed HCT interventions that ranged across multiple medical specialties. There was no standard HCT intervention; characteristics, format and delivery mode varied. Only three studies reported a detailed description of the co-design method(s) used and none reported on the facilitators or barriers. Among the studies, five of Bowen and colleagues' eight dimensions of feasibility were measured.

CONCLUSIONS

Despite the co-design process being neither described or evaluated extensively, all co-designed HCT interventions included in this review were considered to be feasible. Nevertheless, HCT interventions varied in their format and delivery method making it difficult to compare between them. Furthermore, interventions were often condition-specific and not representative of the extensive range of chronic conditions.Implications for RehabilitationHealthcare transition interventions can improve adherence to care, health outcomes, ongoing rehabilitation, and quality of life of adolescents and young adults with chronic conditions.Healthcare transition interventions should maximise long-term functioning and prioritise rehabilitation aimed at enhancing independence and self-management skills, while reducing hospitalisations.The engagement of individuals with lived experience in the co-design of interventions has been strongly advocated as it brings unique knowledge and experience to the research process.Minimal attention has been given to the involvement of adolescents and young adults with chronic conditions in the development of healthcare transition interventions, however, healthcare transition interventions co-designed with adolescents and young adults with chronic conditions are both feasible and acceptable.

Transition from pediatric to adult care in type 1 diabetes mellitus: a longitudinal analysis of age at transfer and gap in care

INTRODUCTION

Adolescents and young adults (AYAs) with type 1 diabetes (T1D) are at risk of suboptimal glycemic control and high acute care utilization. Little is known about the optimal age to transfer people with T1D to adult care, or time gap between completing pediatric care and beginning adult endocrinology care.

RESEARCH DESIGN AND METHODS

This retrospective, longitudinal study examined the transition of AYAs with T1D who received endocrinology care within Duke University Health System. We used linear multivariable or Poisson regression modeling to assess the association of (1) sociodemographic and clinical factors associated with gap in care and age at transfer among AYAs and (2) the impact of gap in care and age at transfer on subsequent glycemic control and acute care utilization.

RESULTS

There were 214 subjects included in the analysis (54.2% female, 72.8% white). The median time to transition and age at transition were 8.0 months and 21.5 years old, respectively. The median gap in care was extended by a factor of 3.39 (95% CI=1.25 to 9.22, p=0.02) for those who did not see a mental health provider pre-transfer. Individuals who did not see a diabetes educator in pediatrics had an increase in mean age at transition of 2.62 years (95% CI=0.93 to 4.32, p<0.01). The post-transfer emergency department visit rate was increased for every month increase in gap in care by a relative factor of 1.07 (95% CI=1.03 to 1.11, p<0.01). For every year increase in age at transition, post-transfer hospitalization rate was associated with a reduction of a relative factor of 0.62 (95% CI=0.45 to 0.85, p<0.01) and emergency department visit rate by 0.58 (95% CI=0.45 to 0.76, p<0.01).

CONCLUSIONS

Most AYAs with T1D have a prolonged gap in care. When designing interventions to improve health outcomes for AYAs transitioning from pediatric to adult-based care, we should aim to minimize gaps in care.

Advancing pediatric primary care practice: Preparing youth for transition from pediatric to adult medical care, a quality improvement initiative

BACKGROUND

Despite well-known guidelines to prepare adolescents to transition to adult care, research has shown that this is done less than 25% of time in pediatric practice. This quality improvement (QI) project aimed to improve the transition readiness process for all adolescents aged 14-18 at health care maintenance visits.

METHODS

A multidisciplinary team conducted a quality improvement initiative in a large, urban pediatric academic teaching practice serving a low-income, multi-ethnic population. The team developed transition interventions through successive Plan-Do-Study-Act cycles. They included a formal transition readiness assessment tool, provider-delivered education related to transition readiness, and delivery of a transition brochure for all adolescents. The team used run charts to follow the rate of formal transitions discussions documented in the electronic medical record.

RESULTS

Over the course of 36 months the outcome measure of provider documented transition readiness discussions increased from 19 to 64% of the time. Over the same course of time, the process measures of transition brochure distribution and completion of the readiness assessment tool increased from 0 to 94% and 0 to 84% respectively.

CONCLUSIONS

QI methodology and multidisciplinary coordinating to streamline workflow, distribution of transition information, readiness assessment and provider discussion and documentation can be successfully incorporated into a busy primary care setting. By formalizing and standardizing the transition readiness process, pediatric providers can improve young adults' readiness to transition to adult medical care.

Survey of US pediatric nurses' role in health care transition planning: Focus on assessment of self-management abilities of youth and young adults with long-term conditions

The survival rates of youth and young adults (YYAs) diagnosed with long-term conditions have improved considerably as 90% now enter adulthood; health care transition planning (HCTP) has emerged as a nursing practice priority. The aim of this national online survey was to investigate the extent to which nurses, recruited from two major United States pediatric nursing organizations are involved with HCTP including assessing YYA self-management abilities (SMA). Findings of a 9-item assessment of self-management abilities subscale of the nurses' role in HTCP tool are reported. The nurse respondents (n = 1269), identified the most frequently assessed SMA was the YYAs' ability to understand and speak about their condition and its treatment (M = 2.3, SD = .89). The least frequently assessed was the YYAs' ability to identify community advocates to help them become more independent (M =1.5, SD = .90). Regression analysis identified significant predictors of the frequency nurses assess YYA for SMA included nurses' level of knowledge, perceived level of importance, HCTP and skills identified in job description, and caring for YYA. Findings indicate HCTP care advancements will necessitate HCTP training and development of nurse-led service efforts to facilitate optimal outcomes for YYA.

Pediatric nurses in pediatricians' offices: a survey for primary care pediatricians

BACKGROUND

The role played by nurses in caring for children in pediatricians' officies in the community is crucial to ensure integrated care. In Italy, pediatricians are responsible for the health of children aged 0-14 years living in the community. This study aimed to describe Italian primary care pediatricians' opinions about the usefulness of several nursing activities that pediatric nurses could perform in pediatricians' offices.

METHODS

An online survey with pediatricians working in primary care in Italy was conducted between April-December 2018. A 40-item questionnaire was used to assess four types of nursing activities: clinical care, healthcare education, disease prevention, and organizational activities. The answers ranged from 1 (not useful at all) to 6 (very useful). Moreover, three open-ended questions completed the questionnaire.

RESULTS

Overall, 707 pediatricians completed the online survey. Participants were mainly female (63%), with a mean age of 57.74 (SD = 6.42). The presence of a pediatric nurse within the pediatrician's office was considered very useful, especially for healthcare education (Mean 4.90; SD 1.12) and disease prevention (Mean 4.82; SD 1.11). Multivariate analysis confirmed that pediatricians 'with less working experience', 'having their office in a small town', and 'collaborating with a secretary and other workers in the office' rated the nurse's activities significantly more useful.

CONCLUSIONS

A pediatric nurse in the pediatrician's office can significantly contribute to many activities for children and their families in the community. These activities include clinical care, healthcare education, disease prevention, and the organizational processes of the office. Synergic professional activity between pediatricians and pediatric nurses could ensure higher health care standards in the primary care setting.

Changing The Face Of Health Care Delivery: The Importance Of Youth Participation

Young people are often the intended audience for health and social programs, yet they rarely participate in the decision-making processes that determine how these programs are designed, implemented, or evaluated. Failing to meaningfully engage young people, well-intended adults may miss opportunities to create relevant and effective programs and policies for youth. This article describes a youth-led health assessment conducted with researchers from an academic medical center accountable care organization and stakeholders from a local community center. We explain the process of recruiting and engaging youth in this project, along with health concerns they identified in their communities via a survey, including mental and sexual health, food access, and community safety, as well as recommendations the youth researchers developed for improving health and tackling inequities. Our findings show that youth participation fosters a deeper sense of empowerment and leadership potential. Policy makers and other health leaders should consider engaging young people as they make decisions about health care delivery.

Pediatric to Adult Epilepsy Transition in Ambulatory Care: Benefits of a Multidisciplinary Epilepsy Transition Clinic

Children with epilepsy comprise 3.2% of the estimated 500,000 youth with special medical needs who move from the pediatric to adult care model annually. These 16,000 children who require transfer each year represent a challenging subset of 470,000 youth living with epilepsy in the United States. Transition and transfer of care are complex and require gradual processes. This period for youth with epilepsy is often associated with inadequate follow-up and increased risk of nonadherence. Furthermore, youth and adults with epilepsy are known to have suboptimal social and emotional outcomes compared with peers, with high rates of under education, underemployment, poverty, and struggles with mental health. The goal of improving social determinants and continuity of care prompted the development of formal epilepsy transition clinics. Multiple clinic models exist, sharing the overarching goal of supporting youth while building self-management skills, tailored to age and developmental level. Early evidence shows that transition discussion leads to statistically significant increases in transfer readiness and self-efficacy in young adults with epilepsy. Our center boasts a 100% attendance rate at our transition and transfer clinic and 78% compliance with follow-up, further demonstrating that patients and families value quality transition programming.

Outcomes of Pediatric to Adult Health Care Transition Interventions: An Updated Systematic Review

PROBLEM

A previous systematic review found that health care transition (HCT) interventions result in positive outcomes related to population health, patient experience of care, and utilization. Since its publication, new national statistics, updated professional guidance, and a growing body of published literature on HCT have prompted the need for an updated systematic review that aims to examine outcomes of the latest pediatric-to-adult HCT interventions.

ELIGIBILITY CRITERIA

Eligible studies were published in English between May 2016 and December 2018, described HCT interventions for youth moving from pediatric to adult outpatient health care, quantitative in design, and peer-reviewed.

SAMPLE

Nineteen articles from a literature search of CINAHL, OVID Medline, PubMed, Scopus, Web of Science were included in this review.

RESULTS

All included studies examined youth with special health care needs. Most of the positive outcomes identified were related to population health, followed by improvements in utilization. All studies mentioned transfer assistance, most described transition planning supports, and almost half reported on integration into adult care.

CONCLUSIONS

This review strengthens the evidence that a structured HCT process for youth with special health care needs can show improvements in adherence to care, disease-specific measures, quality of life, self-care skills, satisfaction with care, health care utilization, and HCT process of care.

IMPLICATIONS

Future research studies should utilize interventions that incorporate all HCT components (planning, transfer, and integration) and assess provider experience of care as well as cost of care.