March 11, 2025

Health Care Transitions

March 11, 2025

Meeting Recording

Attendees: Sarah Corathers, Faisal Malik, Allison Smego, Holly Hardison, Timothy Bol, Don Buckingham, Jaimie Contreras, Briana Vitucci, Siham Accacha, Kari Weier, Katie Craft, Risa Wolf, Tischa Byerly, Jordan Ross, Michael Greenberg, Meredith Wilkes, Inas Thomas, Kate Weaver, Lori Benzoni, Ming Chan Hong, Vana Raman, Michael Goldstein, Amy Ohmer, Charlotte Chen

Agenda:

• Welcome
• Center Sharing, Dr. Smego, Utah Children’s Intermountain Health
• Group Discussion

Center Sharing:

Link to Slides

• Started with no formal process
  • Team formed to include endos, fellows, nurse care coordinator, RN manager, CDCES etc..
  • Used Fishbone to identify common barriers
  • Created Key Driver Diagram to find solutions to the barriers
  • Process Map created to transition process
  • Current PDSA is to establish a transition skills checklist
• “Go and try approach from peds to adult”
  • Allows patients to go and try and adult provider and if it does not click they can come back for supplies and care until they find a new fit
  • Keep an up to date provider list of providers in state and neighboring regions
• Tracking month by month data
  • Anytime seen in pediatric clinic, count restarts

Group Discussion:

• Hopkins Transition Event:
  • Every spring 2 hours on Sunday, virtually
  • 1 hour of rapid fire talks
    • Nurse on prescriptions
    • Doctor on difference between peds and adult
    • Getting accommodations
    • Communication with parents
    • How to eat in dining halls
    • Substances in college
  • 1 hour panel discussion
    • Graduated patients share experiences and helpful tips
      • Patients in college, workforce, etc
    • Seeing patients for longer:
      • What do you do for patients in college?
        • Telehealth for states licensed
        • Switch to every 6 months
        • Education session scheduled for group visits when a lot of the patients come home for college
        • E-visit is a great option for any state
      • Patients who get married?
        • Pregnancy is an automatic referral to adult care, MFM
        • Pregnancy Resource, CCHMC
        • Have had some young moms return to peds care with infants
        • NYU LI: recently had a adolescent patient who pregnancy but due to hospital policy, worked with MFM, and adult and now coming up with policy on how to care
      • How to navigate post 18 year old parents for refills:
        • Advocating for patients to take over this responsibility of care, in transition policy
          • Can denote in EPIC the policy

Next Steps:

• Thank you to those adults who have expressed interest in chairing the group. We are reviewing these requests and will reach out soon.
• If your center is interested in sharing on the next call, please email Holly at hhardison@t1dexchange.org or qi@t1dexchange.org to let us know

Next Call: Monday April 21^st, 2-3pm EST