April 16, 2024

April 16, 2024

Health Care Transitions Working Group

 

Attendees: Shivani Agarwal, Sarah Corathers, Holly Hardison, Michael Greenberg, Ryan Tweet, Jordan Ross, Don Buckingham, Deborah Plante, Tischa Byerly, Siham Accacha, Anita Peoples, Sarah Rosenheck, Laura Waterman, Amy Ohmer, Farahnaz Joarder, Wynola Wayne, Katie Craft, Inas Thomas, Kate Weaver, Monique Maher, Allison Smego, Sheil Dennehy, Danel Tilden, Mark Clements

 

Agenda:

• Review plan to use Got Transition’s Six Core Elements of health care transition (HCT) to guide T1DX-QI HCT efforts
• Define Orientation to Adult Practice core element
• Share successes and challenges with orienting emerging adults with diabetes to adult practice

 

Who: Who performs the orientation?

What: What is included in the orientation?

Where: Where does this happen (virtually, in-person, peds, adult)?

When: When in the onboarding to adult care does this happen?

• Before meeting adult provider for the first visit
• During/immediately after first visit
• Something else

How: How is the orientation tracked and assessed?

• Completion of process
• Acceptability/Utility by patients/providers

Albert Einstein:

• Office Secretary to take care of scheduling
  • Often falls to providers to schedule
• In first visit discuss goals, meet patients where they are
  • Introduce team of members on receivership side
• Tracking on paper

University of Washington:

• 2 part transition onboarding
  • Nurse will do more formal welcome to adult care, in a separate visit
• Where to in case of emergency
• Who to call
• Have new transitions sign up for patient portal before visit

OHSU

• Evolving program, crated a half day multidisciplinary session
  • Session led by behavioral health
  • Rolls into 1-1 education visit then 1-1 medical visit
  • 1 session a month
  • Average group size 3-5

 

Expectations on Meeting Schedule:

Albert Einstein

• Physician initially and then NP in second half of day
  • Education visits turned into medical visits
• Frequency depends on patient, and insurance

University of Washington

• Does not explicitly share frequency

 

Transitions of Care Geography shift:

• State diabetes camp is a great resources to tap into
• Peds endo list
• Adult side does not typically have list
  • Refer to local major medical centers

 

Language of framing transfer:

• University of Michigan Diploma Project
  • Patients will receive a diploma upon completion of care in pediatric center before moving to adult care
• Using graduation can be a simple way of shifting the idea that moving from peds to adult is scary and is seen more of an accomplishment

 

Link to Recording; https://youtu.be/6Fk4XRK2OmU

 

Next Call: Tuesday May 14^th 2-3pm EST