July 9, 2024

HCT July 9 Slides

Health Care Transitions Meeting

July 9, 2024

Attendees: Faisal Malik, Sarah Corathers, Shivani Agarwal, Holly Hardison, Amy Ohmer, Lori Benzoni, Beth Edwards, Jordan Douglas, Don Buckingham, Katie Craft, Michael Greenberg, Jessican Schmitt, Alissa Guarneri, Anita Peoples, Jennifer Iyengar, Ryan Canter, Tischa Byerly, Malak Abdel-Hadi, Allison Smego, Kate Weaver, Meredith Wilkes, Andrea Mucci, Inas Thomas, Risa Wolf

Agenda:

• Define “Transfer of Care & Transfer Completions” core elements for pediatric diabetes care
• Review T1DX-QI annual survey data on core element #5 & #6 for pediatric diabetes care
• Define “Initial Adult Practice Visit & Ongoing Care” core elements for adult diabetes care
• Share successes and challenges with core elements #5 & #6 for pediatric and adult diabetes care
• Discuss plan to transition to developing T1DX-QI quality measures for health care transition

Core Element 5: Preparation of Transfer

• Nationwide- transition spiral bound book
  • Has adult endo come every Thursday to see patients (in future planning to see only those patients who are getting ready to transfer)
• Cincinnati, 1 page essential history, and social history (3 most relevant things to connect)
  • Last progress note to serve as summary
• Albert Einstein
  • Most referrals coming from inside institution
  • Transition summary used to gain trust on adult side
  • Barriers, Social History
• University of Washington
  • Use same note template on both the peds and adult side
  • Knowing those personal touchpoints are so important
  • Having those personal information points show unity in programs as well from peds to adult
• Jessica Schmitt suggestion “Does anyone have the patient contribute to the transition packet? ie: “I want my adult provider to know….”   We do not (UAB), but I wonder if there is a role / opportunity for this”
• Cleveland
  • Had patients who were ready to transfer “take a field trip” to the adult clinic to gain familiarity with new center
  • Creating list of provider by location

Core Element 6: Completion of Transfer

• Seattle
  • Using EMR as a tool to track and make sure patients have completed the transfer
  • Uses EMR to track referrals as well
  • Transition Coordinator to do this, but only takes 1 hour of FTE
• University of Michigan
  • Long wait time for new patients to be seen

Measures:

• Increase % pediatric patients with documented transition plan from xx to yy
• Component of transition to include what is most meaningful to the patient
• Rolling out a measure at a time to focus on reliability

Measure Overview

Link to Recording: https://youtu.be/sDl8Sop0Kdo

Health Care Transition Working Group Page: https://t1dx-qi.t1dexchange.org/work-groups/transitions-of-care/

*Reminder NO August Call, but separate peds and adult calls in September (poll will be shared)