May 13 2023

Leadership Strategy meeting, May 13, 2023 

Breakout topic: Transitions of Care 

Link to Recording 

Breakout attendees: Amy Ohmer, Don Buckingham, Donna Eng, Faisal Malik, Grace Nelson, Holly Hardison, Ines Guttmann-Bauman, Laura Jacobsen, Manu Kamboj, Mark Clements, Nicole Rioles, Sarah Corathers, Shivani Agarwal, Siham Accacha, and Vana Rahman. 

Challenges 

• How do we partner with adults? (“Everyone” needs to be interested in this topic.) 
• Closing the loop. (How long do we want the transition period to last?) 
• Are transitioning patients retained in care? Are they experiencing DKA? 
• Adult care has limited access. No room for new pts. 

• Adult practice that is new to the transitioning patient doesn’t “know” the patient. No acknowledgement or understanding of their experiences or knowledge 

Goals 

• Curate best practices 
• Describe gaps 

• Develop an adult “team” that can partner with peds for seamless transitions. Bring in your adult counterpart so that they can be part of the intervention 

Beliefs 

• Timelines need to be personalized 
• Should be a celebration of “graduating from peds to adult care” 

Conditions 

• Variations by state 
• The framework of Transitions sometimes has negative connotations “kicked out of peds.” We should be framing this as a positive milestone in development. We can say they are “graduating” to adult care to bestow a sense of accomplishment for their independence and growth. 
• Transitions age varies by clinic. Intermountain transitions at 18. Nationwide at 21. 

• Several clinics have current practices, having an adult provider see pts who are transitioning care. Some have peds providers who occasionally practice in adult setting to transition care successfully 
• Some clinics have a “transitions clinic,” but access is limited. 
• Some clinics are using the Got Transition survey now but would like to pivot away from it 
• Status of tools used by clinics 

• OHSU: made their own in Epic 

• Seattle: READDY 
• Cincinnati: READDY 
• Johns Hopkins: checklist plus READDY for readiness 
• UFL: use survey for 18+. Not used for younger patients. Transitions Navigator in Epic is clunky. Uses Pathway to Independence 
• Nationwide: adult provider comes 1xweek to see patients 

• NYU Mineola: peds endo travels to adult clinic with educator and does 10 min hand-off to introduce the pt to adult care. Convenience factor: share same building and floor and there is a “transitions” room. 

Next steps 

• Faisal, Sarah, and Shivani will co-lead Transitions 
• Transitions group will meet monthly 

• T1DX-QI will send Doodle Poll for meeting scheduling 
• Next meeting: agree on Aim Statement and interventions