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Rachel Bensen, MD, MPHStanford University School of Medicine/ Stanford Children’s Health
Stanford Clinical Excellence Research Center
Human-Centered Design to Improve Value in Transition
to Adult Care
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Consensus Statement on Transitions (2002, 2011)
Purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of young people with chronic medical conditions, as they move from child-centered to adult-oriented health care system
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The Human Face of Transition
Veronica21years
Liver Transplant
Jose20yearsCongenital Heart Disease
Gabe18yearsType I Diabetes
Diana22years
Cerebral Palsy & Cognitive
Impairment
Nevaeh19yearsNeuro-
muscular Disorder
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Build self-management – for youth & caregiversCoaching to develop skills needed for successful transition Treatment of anxiety & depression Peer support & mentorship
Engage the receiving care teamEasy access to history and age/disease related information
Guide patients & families through the transferTransition guide utilizing two-sided checklist Portable medical summaryLink to community resources
Bridging the Gap:Efficiently Assuring Safe Transition from Pediatric to Adult Care for Youth with Childhood Onset Chronic Disease
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Continuous Tailoring to NeedsDial services up and down to
match evolving needsContinuous engagement with prompt
responses to avoid acute crises
Medical Complexity
Activation for Disease Self-Management
Peer Support Behavioral Health
Ongoing engagement for 6-12 months POST TRANSFER to assure safe landing
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Our PilotsSite 1
• Starting in Type 1 Diabetes Clinic
• Interviews completed; Focus Groups this month
• Patient enrollment to begin May 2015
• Goal to eventually extend program system-wide
Site 2
• Complex Primary Care
• Enrollment began February 2015, but has been challenging
• Several ongoing transitions initiatives
• Limited piloting of coaching & online CBT
• Planning of broader pilot is underway
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Thank you
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Young Adults with Childhood Onset Chronic Disease
• United States
Age 15-24 years
US: 43.6 million
18% have special health care needs nationally: 7.9 million
500,000 - 750,000 transfer to adult care each year
2010 US Census Data
http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf
• California
Age 15-24 years
CA: 5.6 million
18% with special health care needs: ~1 million
60,000-90,000 transferring per year
2010 US Census
http://www.dof.ca.gov/research/demographic/state_census_data_center/census_2010/documents/CALIF_2010SF1_PROFILE.pdf
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