February 12, 2025

Health Care Transitions

February 11, 2025

Meeting Recording

Attendees: Sarah Corathers, Faisal Malik, Holly Hardison, Don Buckingham, Rebecca Patterson, Amy Ohmer, Beth Edwards, Alissa Guarneri, Mai Train, Racheal Mullin, Lori Benzoni, Malak Abdel-Hadi, Vana Raman, Christy Foster, Jessica Schmitt, Ines Guttmann-Bauman, Andrea Mucci, Emily DeWit, Tischa Byerly, Farahnaz Joarder, Ming Chan Hong, Andrew Welch, Monique Maher, Allison Smego, Kate Weaver, Jordan Ross, Abha Choudhary, Jenny Pfieffer, Deborah Plante, Meredith Wilkes, Wynola Wayne, Inas Thomas

Agenda:

• Welcome and Introductions
• Review of Pediatric Measure
  • Updates from centers on tracking and reporting
• Review of Adult Measure
  • Updates from centers on tracking
• Adult Co-Lead Discussion

Pediatric Measures:

• Got transitions framework as basis
• Creating quality measure around readiness assessment
  • centers query baseline data of adolescents with T1D % age > 16 with an assessment within past 12 months
  • % T1D age > 18 with transition readiness assessment within past 12 months
• Follow up survey of network on how we are standardizing steps on transition
• Having a very clear documentation on transition
  • Making sure the patient really understands what the transition will look like and the importance of following through on the transition appointment into adult care

Adult Measures:

• Track retention as a measure
  • 1 year after transition would be good proxy for established receivership up to age 26
  • Looking at the referrals to make sure they were completed
    • Seattle adults have an epic process where older adults cannot be booked into a new patient (YA) slot
    • Challenges of getting a referral schedule (patients not getting calls etc..)
    • Challenges going from date of referral to date of first visit
      • Transition flowsheet built for newly transitioning patients
      • Currently providers are updating the flowsheets

Candence of Calls moving forward:

• Potentially have 1-2 calls as just separate groups adults and peds
• Recommend keeping majority calls as combined
• More focused calls to discuss project
• Adult perspective: anyone who is interested let us know