Piloting a Transition of Care Curriculum at Two Bi-coastal Medicine-Pediatrics Residency Programs.

BACKGROUND: Lack of consistency in primary care residency training exists in transitions of care (TOC) of adolescents from pediatric to adult medicine, which can lead to conflicting or incomplete training. To fill this gap, we developed a curriculum based on the Got Transition Six Core Elements and piloted it at two bicoastal, academic Medicine-Pediatrics (Med-Peds) residency programs. OBJECTIVES: The goals of this project are to increase resident TOC knowledge, increase transition discussion comfort and skills, and obtain feedback for curriculum improvement. METHODS: Two educational sessions were held at both institutions between 2020-2021. Of 32 potential resident participants, 26 participated in session one and 22 participated in session two. Sessions included a didactic presentation, small group activities, and a guest speaker discussing transitional experience. Electronic pre-session, post-session, and retention surveys evaluated resident knowledge, comfort, and self-reported skills of TOC. A Hybrid Type II design was used with mixed methods to evaluate curriculum effectiveness and implementation. RESULTS: The first and second sessions had 81% and 68% attendance, respectively. Eighty-four percent completed the pre-session survey, 65% completed the post-session survey, and 68% completed the retention survey. TOC knowledge increased by 19% overall (p<0.001). First-year residents gained the most knowledge and implementation skills. Residents participating in alternating medicine and pediatric clinics gained more knowledge than those in a combined Med-Peds clinic (p=0.001). Comfort increased for both initiating and continuing TOC discussions after the first session. Knowledge retention was not statistically significant. CONCLUSION: A standardized TOC curriculum can improve resident knowledge and is easily implemented at multiple institutions. Early-in-training residents and those in alternating medicine and pediatric clinics particularly benefit.

A Communication Model to Bridge Adolescent Patients, Caregivers, and Physicians in Transitions of Care.

A transition of care (TOC) process from pediatric to adult medicine ensures that adolescents receive ongoing care into young adulthood, a time of high risk for preventable morbidity and mortality. We explored patient, caregiver, and physician perspectives on ways to improve TOC communication with healthy adolescents. Two researchers conducted key informant interviews with healthy 12- to 18-year-old adolescents, their caregivers, and primary care physicians working in pediatric, internal, and family medicine. Data saturation was reached after interviewing 12 adolescents, 10 caregivers, and 36 physicians. Three themes were identified: perceptions of TOC; effective communication among the triad of adolescents, caregivers, and providers; and early communication about TOC preparation. From these themes, a model of communication was identified and adapted, outlining the communication skills and responsibilities for physicians and patients during TOC. Physicians must understand how to use strong, consistent, adolescent-centered communication to execute effective TOC.

Improving Transitions of Care for Healthy Adolescents and Young Adults.

OBJECTIVES: To explore the gaps in care within the transition process from pediatric to adult medicine for healthy and noncomplex adolescents and young adults and to highlight the importance of identifying and adapting interventions to improve transitions for this population. METHODS: Three researchers independently completed searches in PubMed, PsychINFO, and CINAHL Complete. The review used the following inclusion criteria: English-language original research articles published between January 2007 and January 2018 involving care transitions for male and female patients ages 13 to 24 years with diagnoses that may be managed only by a primary care provider. Studies were excluded if they were reviews or commentaries, included only specialist providers, or primarily investigated children with special healthcare needs. The articles selected based on these inclusion and exclusion criteria, as well as those identified through review of references of included articles and known articles not found through those searches, were analyzed for suitability. RESULTS: Nine studies were included in the review. Limited consensus existed on how transitions of care should be approached for healthy and noncomplex adolescents, despite the 2002, 2011, and 2018 policy statements and clinical reports providing guidelines on transition processes. Perceptions about when to initiate the process, what to discuss about transitions, and how to approach those conversations varied among providers. CONCLUSIONS: The literature is limited regarding transitions of care from pediatric to adult medicine for healthy and noncomplex adolescents and young adults. Areas for intervention were identified from these studies and have yet to be explored. Additional research is needed to overcome transition obstacles and to tailor interventions to help healthy and noncomplex adolescents and young adults at this vulnerable time of their lives.

Transitions of Care for Healthy Young Adults: Promoting Primary Care and Preventive Health.

The transition of care between pediatric and adult medicine is a challenging time for patients and physicians. This longitudinal process encompasses much more than the physical transfer of a patient between providers. Established transition of care processes and literature exist for many chronic disease populations, but little focus has been directed toward the transition of care and the delivery of preventive medicine for healthy young adult patients. The 18- to 30-year-old age group is a heterogenous population that often engages in high-risk behaviors and has high rates of preventable morbidity and mortality. A significant number of these patients do not receive routine primary care and are high users of costly emergency services. Without a continuous source of care, many young adults do not receive age-appropriate screening or preventive health guidance. Structured transition practices improve outcomes in the chronic disease population, and anticipatory guidance has a positive effect on patient lifestyle modification. Adult providers should use these practices to ensure the successful integration of healthy young adult patients into an adult medical home. By establishing an ongoing source of preventive care, providers could reduce morbidity and mortality in this vulnerable population.

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

PURPOSE: Youth and young adults require systematic planning, transfer and integration into adult healthcare. A national health care transition (HCT) learning network (LN) shared strategies during monthly calls to improve HCTs using Got Transition™'s Six Core Elements. Among LN participants, we conducted a pre-post mixed-methods evaluation of this evidence-informed process improvement framework. DESIGN AND METHODS: Leaders from seven health systems in the LN recruited 55 participating practice sites (12 primary care, 43 specialty care, 47 pediatric care, and 8 adult care). Got Transition's Current Assessment (CA) of HCT Activities (possible score: 0-32) assessed implementation of HCT process improvements in all 55 sites at baseline (2015-2017) and again after 12-18 months. Pre-post results were compared overall and by type of practice (primary vs. specialty, pediatric vs. adult). In early 2018, health system leaders qualitatively described factors impacting HCT process implementation. RESULTS: Overall, baseline CA scores averaged 10.7, and increased to 17.9 after 12-18 months. Within each clinical setting, scores increased from: 10.8 to 16.5 among 12 primary care sites, 12.8 to 17.1 among 43 specialty sites, 12.4 to 17 among 47 pediatric sites, and 12 to 16.9 among 8 adult sites. All changes reached significance (p < 0.05). Qualitative feedback offered valuable feedback about motivators, facilitators and barriers to HCT process improvement. CONCLUSIONS: Participating systems made substantial progress in implementing a structured HCT process consistent with clinical recommendations using the Six Core Elements. PRACTICE IMPLICATIONS: The diverse perspectives of participating health systems provide a model for creating sustainable HCT process improvements.

Adolescents with sickle cell disease in a rural community: are they ready to transition to adulthood?

OBJECTIVES: Most patients with sickle cell disease (SCD) survive to adulthood; however, young adults with SCD have high rates of morbidity and mortality and may struggle in the transition to a healthy adulthood. The purpose of this study was to determine the readiness of a rural SCD population for the transition to adulthood and adult medical care. METHODS: Adolescents and young adults who were current/former patients of a rural pediatric practice were surveyed. Assessments included difficulty dealing with daily care issues and perceived/encountered barriers to transition. Adolescents were asked if a doctor had discussed transition to adult care. Young adults also were asked about satisfaction with their transition experience and about the utility and composition of a transition program. RESULTS: Surveys were completed by 13 adolescents and 5 young adults. Adolescents reported difficulty leaving their pediatrician (62%) and knowing how SCD differs from other types of anemia (54%). They had concerns about finding an adult doctor (54%), arranging transportation (54%), preparing to use an adult hospital (46%), and handling financial issues (46%). Two-thirds had not discussed or did not know whether their doctor had discussed transitions. Young adults described difficulty leaving their pediatrician (100%), finding an adult doctor (80%), keeping a job (60%), knowing what to expect (40%), and knowing how to pay for medical care (40%). Two-thirds were not satisfied with their transition and all believed a transition program would be helpful. Services suggested for a transition program to provide included information about adult providers/adult healthcare services, ways to take control of one's own care, and helping adult providers understand more about SCD. CONCLUSIONS: Adolescents with SCD in a rural community identify potential barriers in the transition to adult health care. Several barriers mirror what young adults report encountering. A rural SCD transition clinic can provide individualized preparation to promote a successful transition to adulthood.

Resident preferences for a curriculum in healthcare transitions for young adults.

OBJECTIVES: Numerous national groups recognize that healthcare providers should be trained to care for patients with special healthcare needs who are transitioning from pediatric to adult health care, yet there is little emphasis on this training in most residency programs. The survey discussed here assessed resident preferences for a curriculum that addresses healthcare transitions for young adults. METHODS: Trainees in primary care residency programs at three institutions in South Carolina were surveyed. Residents were asked about their preferences for timing and modality of transition education and desire to see patients older/younger than dictated by training. Residents also ranked topics of transition by level of need/interest. Comparison of responses was analyzed via t tests and the Fisher exact test. RESULTS: Respondents (n = 84) represented three institutions and eight training programs. Eighty percent of residents prefer that a curriculum be continuous throughout training and include clinical experiences (79%), case discussions (60%), and lectures/didactics (56%). Pediatric residents were more likely than were internal medicine residents to value seeing patients older/younger than their program dictates (84% vs 42%; P < 0.01). Internal medicine residents were more likely than pediatric residents to rank as high need/interest "medical knowledge of pediatric disease persisting into adulthood" (77% vs 47%; P= 0.05) and "caring for adult-aged patients reliant on caregivers" (53% vs 9%; P < 0.01). CONCLUSIONS: Residents prefer a healthcare transition curriculum that is continuous throughout residency and uses combined modalities for topic presentation. Residents training in different disciplines have varied levels of need/interest for transition-related topics and this should direct the development of healthcare transition curricula.

Transition medicine: a review of current theory and practice.

Every year more than 500,000 children with special health care needs (CSHCN), patients who need more consistent medical care or face significant consequences and complications, transition to adult-oriented providers. Yet these patients may encounter even greater difficulty in transitions of care than healthy adolescents and young adults, whether it is finding a provider who is comfortable managing their condition, re-establishing trust with a new provider, having providers address their unique psychosocial needs, or maintaining sufficient insurance coverage. Several models have been described with the goal of improving the transition process for patients, families, and providers. However, little evidence exists as to the actual impact of these programs on patient outcomes. This review highlights current understanding and expectations of transition for young adults with special health care needs, describes the state of transition medicine in South Carolina, and outlines areas for research and improvement on the local, regional, and national level.

Impact of practice policies on pediatric immunization rates.

OBJECTIVE: To describe the relationship between practice policies and rates of up-to-date (UTD). STUDY DESIGN: Analysis of data from the 2004-2006 National Immunization Survey (NIS). Practice policies evaluated are immunization provider involvement in a vaccine registry, participation in the Vaccines for Children (VFC) program, and administration of hepatitis B vaccine at birth. The primary outcome is rates of being UTD with the 4:3:1:3:3 vaccination series for children age 19 through 35 months. RESULTS: The overall rate of UTD is 80.8%; 53.3% of children had providers administer hepatitis B vaccine at birth, which was associated with significantly higher rates of UTD (79.9% vs. 83.1%, P < .01). Children with multiple vaccine providers had lower rates of UTD versus those with only 1 vaccine provider (77.3% vs 82.5%; P < .01). In multivariable analysis, participation in VFC (OR 1.59, 95%, CI 1.16-2.2) and administration of hepatitis B at birth (OR 1.25, 95% CI 1.05-1.5) increased the odds of UTD. Provider participation in a vaccine registry did not significantly impact rates or likelihood of UTD. CONCLUSIONS: Immunization provider policy decisions, including administration of hepatitis B at birth, participation in VFC, and a focus on continuity of care, can improve rates of UTD for children in their practice.