June 11, 2024

T1DX-QI HCT Workgroup_Core Element #4

Health Care Transitions Working Group

June 11, 2024

Attendees: Faisal Malik, Sarah Corathers, Shivani Agarwal, Holly Hardison, Jennifer Iyengar, Beth Edwards, Kate Weaver, Andrew Mucci, Anita People, Jordan Ross, Jessica Schmitt, Stephanie Sund, Tischa Byerly, Charlotte Chen, Jason Sloane, Michael Greenberg, Mark Clements, Ines Guttmann Bauman, Deborah Plante, Inas Thomas, Lori Benzoni, Leah Tyler, Mai Tran, Farahnaz Joarder, Vana Raman, Allison Smego

Agenda:

• Review plan to use Got Transition’s Six Core Elements of health care transition (HCT) to guide T1DX-QI HCT efforts
• Define “Transition Planning” core element for pediatric diabetes care
• Review T1DX-QI annual survey data on core element #4 for pediatric diabetes care
• Define “Integration into Adult Practice” core element for adult diabetes care
• Share successes and challenges with transition planning of emerging adults with diabetes

Pediatric:

• Cincinnati using flowsheets to build readiness in EHR system
  • Transition Planning elements built into discrete data elements for report and follow up
• Seattle have created program for both institutions between peds and adults
  • Integrate some of the adult care model into peds to prepare for transition
  • Same note template between adult and peds for seamless care

Adult:

• Montefiore relies on hospital communication systems like text reminders and MyChart messages for appointment tracking
  • Nurses reach out as well for communication
• University of Washington challenges getting patients in the door
  • Send pre-visit My Chart message to ensure members are on platform before visit to get connected to clinic
  • Reschedule people who no-show but those who cancel are harder to track

Challenges with Change:

• Tips for patients/parents who are supportive in transitioning?
  • Relationships matter in medicine
    • Reassuring that “You know the others on the adult side”
    • Having members on adult side that are comfortable with this population of young adults
  • Having a “Speed dating sheet” with providers in the area with areas of interest to share with patients before they transition
• No Show Policy:
  • At Washington 3 limit reach out per center administration but patients can reach back out
    • Positive relationship is if Seattle Children Provider notices that they are still filling medication, they can figure out why that patient did not transition then encourage to try again
  • Primary Care
    • Adult providers can provide some care that is traditionally given by primary care, but antibiotic administration is where most draw line
    • Washington Adult has primary care in same building, but patients are rarely going to receive care
    • Dependency on endo for primary care is a challenge

Link to Recording: https://youtu.be/xs6QrOveOAc

Link to Working Group Page: https://t1dx-qi.t1dexchange.org/work-groups/transitions-of-care/