April 21, 2025

Health Care Transitions

April 21, 2025

Meeting Recording

Center Presentation Slides

Attendees: Sarah Corathers, Faisal Malik, Amanda Palmer, Risa Wolf, Malak Abdel-Hadi, Allison Smego, Timothy Bol, Don Buckingham, Mark Clements, Abha Choudhary, Joarder Farahnaz, Daniel Tilden, Deborah Plante, Christy Foster, Michael Goldstein, Ming Chan Hong, Jordan Ross, Rebecca Patterson, Sarah Baker, Jessica Schmitt, Inas Thomas, Mai Tran, Vana Raman, Kari Weier, Kayla Grace Zimmerman,

Agenda:

• Welcome
• Center Sharing, Dr. Risa Wolf and Amanda Palmer: Johns Hopkins Pediatric Diabetes Center Transition Program
• Group Discussion

Center Sharing:

Link to Slides

• Amanda provided guidelines to assist in their transition process: a transition preparation and readiness assessment, diabetes transition after high school webinar, and transition tracking to ensure their young adults are making it to adult care.
• In addition, nutrition quizzes are utilized to prepare for college or work and annual psychology visits are to help young people prepare.
  • Created a team of endocrinologists, fellows, nurse care coordinator, nurse manager, and CDCES to help young people navigate.
  • Helps young people prepare for making their own choices.
  • As a team they decided to start transition one year after high school graduation to avoid overwhelming young people who are already going through many changes.
• Diabetes Transition/Off to College Event.
  • A very popular two-hour annual event held on Zoom. Zoom was deemed to be a better medium than in person after family feedback.
• Details regarding the plan for a young person’s final pediatric visit were shared:
  • Medical summary is provided to patient, their pediatric provider contacts and adult provider for a warm handoff, and the pediatric practice tracks that patient.

Group Discussion:

• Roughly 30 families, including parents, attend. No recording of the session for privacy. It’s roughly two hours, starting at 10:00am and running to noon.
  • Dr. Wolf and Amanda come prepared with questions to get the discussion started.
• There are no bilingual classes, as that is not a priority for their region.
• Discussion occurred about their Smart Aim, and the methods for tracking patients who have transitioned.
• When attending college outside of the area, most patients come back home during breaks and schedule their appointments.
  • With a lot of people on HCL, their data is available even while they’re away.
• A few hours a week are spent on this with visits tracked in a Spreadsheet.
• Length of visits can approach an hour, depends on how many members of the care team are involved and the READDY questionnaire is provided annually.
• Additional discussion occurred about if other centers are doing anything similar. Children’s National does something similar but that meeting is held in the evenings for an hour and half.

Next Steps:

• If your center is interested in sharing on the next call, please email Tim at tbol@t1dexchange.org or qi@t1dexchange.org to let us know.
• New meeting invites may be needed to fix issue with Teams saving the recorded meetings.

Next Call: Tuesday May 13^th, 2:30-3:30pm EST