August 12,2025 (Adult Meeting)

Attendees: Tim Bol, Don Buckingham, Claire Rainey, Jenni Iyengar, Farahnaz Joarder, Amy Ohmer, Briana Vitucci, Kate Weaver, Andrew Welch, Deborah Plante

Goal: Build a metric for November before the Learning Session. Take shared learning and best practices from different centers and then move into the next phase.

• This measure will be on a mapped data file and submitted to the Exchange.
• Two options: create a new measure or modify an existing measure – we will likely be going with option 2.
• Long lag time with this measure is a drawback for QI work.

Discussion:

Can we define a “transition” patient based on age? What age range would you use? Clarification was provided about what a year means, in this case it is January to January.

• Farahnaz Joarder, MD, OHSU: in terms of a measure, age is easiest to identify. Already tracking transfer patients at OHSU. Sorted data b rural: urban, gender, age.
• How do we measure success? Can we use A1c? Can we link this to diabetes distress? Which a1c and when?
• We want to see patients at least twice a year but three/year is ideal. We don’t want to tighten up the measure more than what the clinic would normally suggest for their patients.
• Andrew Welch, MD, University of Cincinnati: Raised a question about young women who become pregnant.

What age range would you use?

• Dr. Iyengar – 18-23,
• Dr. Joarder – 18-25,
• Dr. Welch – most are coming in after graduating college, a lot of patients come in after 24, 25 years old.
• Dr. Iyengar – lets go 18-30.

Amy Ohmer asked if holding on to patients longer leads to better outcomes?

Question for Anton – what percentage of ped centers are mapped vs adult centers?

Dr. Welch had other thoughtful considerations from experience in his clinic:

• Consider doing things like having a flowsheet that asks someone on their first visit if they are a transfer patient or not.
• Another way to look at it would be to track number of transition patients who do not have a scheduled follow up appointment at any point in time.
• For QI purposes, he likes a faster measure, like 2nd visit within 4-6 months of 1st visit, since it can be tracked and acted upon more rapidly, with a secondary measure of 3 visits within one year.
• We should track engagement after that first visit and perhaps try to have both measurement periods.
• “The providers at CCHMC typically are licensed to see patients up until 24 years, so will transfer the majority of them around that age to adult care”

Dr. Iyengar is reaching out to Anton for further clarification:

• Get some clarity on who is a new patient, have two metrics – one year and a second metric with shorter lag time. We should do six months to avoid scheduling delays due to capacity issues.

Meeting Recording:

https://youtu.be/XJokh3Qrbbk