February 13, 2024

T1DX-QI HCT Workgroup_Core Element #2

Transitions of Care Working Group

2/13/2024

Attendees: Faisal Malik, Shivani Agarwal, Sarah Corathers, Holly Hardison, Don Buckingham, Katie Craft,  Julie Park, Deborah Plante, Michael Goldstein, Risa Wolf, Charlotte Chen, Brandon Gale, Inas Thomas, Vana Raman, Wynola Wayne, Meredith Wilkes, Lauren Waterman, Ines Guttmann Bauman, Daiel Tilden, Kate Weaver, Allison Smego, Mark Clements, Manu Kamboj, Farahnaz Joarder, Monique Maher, Ryan Tweet

Agenda:

• Review plan to use Six Core Elements
• Define Tracking and Monitoring Core Elements
• Review T1DX-QI Annual Survey on Core Element 2
• Share Successes and Challenges with Tracking

Six Core Elements:

• Link to manuscript
• Just under 50% of pediatric centers maintain a registry of transition aged youth

Examples:

• Cincinnati uses flow sheets in Epic
• Johns Hopkins uses flow sheets to track dates and discussion
  • Making sure to remind faculty to use
• BDC, split ready, 1 process a year
  • Work with epic analyst to make note template, auto populates into flowsheet
• UCSF peds, uses excel spreadsheet to keep track
• Michigan Adult, transition dashboard to track receivership
  • Referral order, options for clinic and education or just education

• Kansas City, custom redcap in transition from Childrens Mercy
• Childrens Mercy, document in cerner powerforms
  • See transfer order
  • Hospital based mobile app for education
• University of Washington, using READDY as baseline assessment
  • Patients fill out READDY every visit
  • 18-23 scheduled in new adult patient
• OHSU adult, dedicated scheduler tracking referrals but informal on excel
  • EPIC transition tool being piloted to track transition readiness

Resources:

• Use this link to view Seattle and Cincinnati examples on the Health Care Transition page on the member website

Link to Recording: https://youtu.be/QGivAScg3k4