CENTER FOR HEALTH CARE TRANSITION IMPROVEMENT IMPLEMENTATION AND EVALUATION OF TRANSITION QUALITY IMPROVEMENTS IN PEDIATRIC AND ADULT SETTINGS Peggy McManus,

CENTER FOR HEALTH CARE TRANSITION IMPROVEMENT

IMPLEMENTATION AND EVALUATION OF TRANSITION QUALITY IMPROVEMENTS

IN PEDIATRIC AND ADULT SETTINGSPeggy McManus, MHSGot Transition/Center for Health Care Transition ImprovementThe National Alliance to Advance Adolescent Health

Greenville Health SystemTransitional Care ConferenceMay 15, 2015


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Disclosures

• I have no commercial relationships to disclose.

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Presentation Learning Objectives1. Understand latest developments in clinical and measurement

tools for transition from pediatric to adult health care. 2. Review examples of QI strategies to incorporate transition

core elements into 3 types of practices/systems: academic primary care settings, academic subspecialty clinics, and a Medicaid managed care plan.

3. Identify innovative payment strategies for transition.4. Learn about new health care transition resources for youth

and families.

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Transition Goals

• To improve the ability of youth and young adults to manage their own health and effectively use health services

• To ensure an organized clinical process in pediatric and adult practices to facilitate transition preparation, transfer of care, and integration into adult-centered care

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Got Transition/Center for Health Care Transition Improvement

• Funded by federal Maternal and Child Health Bureau to:

1. Spread transition quality improvements2. Provide education/training to health professionals3. Expand youth/young adult and family engagement 4. Improve transition policy5. Serve as a clearinghouse (www.GotTransition.org)

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http://www.gottransition.org/


Making the Case for Transition Improvements

Health is diminished:• Youth often unable to name their health condition, relevant medical

history, prescriptions, insurance source• Adherence to care is lower and medical complications are increased• Youth and families are worried Quality is compromised:• Youth, young adults, and families are dissatisfied about lack of

preparation, information about adult care, vetted adult providers, communication between pediatric and adult providers, and sharing of medical information.

• Discontinuity of care and lack of usual source of care are commonCosts are increased:• Increased ER, hospital use, and duplicative tests result

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US and SC Transition Performance • National data – from 2009/10 – show that 60% of YSHCN are not receiving

needed transition support:– Health care providers (HCP) discussed shift to adult provider– HCP encouraging youth to take responsibility for own health care

needs– HCP discussed changing health needs as youth becomes adult– Discussed future insurance needs

• SC – show that 59% are not receiving needed support – similar to US• However, these national findings overstate transition performance -- if

perceived need was removed from the transition question, results would show that 90% of YSHCN are not receiving transition support.

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TRANSITION FERVOR

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State of Health Care Transition from Pediatric to Adult Health Care

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AAP/AAFP/ACP Clinical Reporton Health Care Transition*

• In 2011, Clinical Report on Transition published as joint policy by AAP/AAFP/ACP

• Targets all youth, beginningat age 12

• Algorithmic structure with:– Branching for youth with special

health care needs– Application to primary and

specialty practices • Extends through transfer of care to

adult medical home and adult specialists

*Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home(Pediatrics, July 2011)

Age12

Youth and family aware of transition policy

Age14

Health care transition planning initiated

Age16

Preparation of youth and parents for adult approach to care and discussion of preferences and timing for transfer to adult health care

Age18

Transition to adult approach to care

Age18-22

Transfer of care to adult medical home and specialists with transfer package


Six Core Elements of Health Care Transition: QI Model

• Original Six Core Elements (1.0), developed in 2011, as QI strategy based on AAP/AAFP/ACP Clinical Report algorithm with set of sample tools and transition index

• New Six Core Elements (2.0), developed in 2014, incorporate results from several transition learning collaboratives, reviews by over 100 pediatric/adult clinical experts and consumers, and extensive review of literature

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Six Core Elements of Transition

• Discuss Transition Policy

AGE 12-14

• Track progress

AGES 14-15-16-17-18 • Assess skills

AGES 14-15-16-17-18

• Develop transition plan

AGES 14-15-16-17-18 • Transfer

documents

AGE 18-21

• Confirm completion

3-6 months after transfer

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TransitionPolicy

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TransitionTracking

andMonitoring

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TransitionReadiness

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TransitionPlanning

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Transferof Care

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TransitionComple-

tion


Six Core Elements 2.0 (See Side-by-Side Handout)

Transitioning Youth toAdult Health Care Providers

(Pediatric, Family Medicine, and Med-Peds Providers)

Transitioning to an Adult Approach toHealth Care Without Changing Providers

(Family Medicine and Med-Peds Providers)

Integrating Young Adultsinto Adult Health Care

(Internal Medicine, Family Medicine, and Med-Peds Providers)

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Transitioning Youth to Adult Health Care Providers: A Closer Look

• For use in pediatric practices and family medicine and med-peds caring for teens who will be leaving their practice

• Other 2 packages follow 6 core elements, but are modified for: youth not changing their provider and for young adults going into adult health care

• Keep in mind that these can be customized with your own practice or health plan logo

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Element 1. Transition Policy

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• Make larger



DE

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CENTER FOR HEALTH CARE TRANSITION IMPROVEMENT 19









• Sample transfer letter provided to adult provider with – Appropriate documentation (readiness assessment, medical summary and emergency care

plan, plan of care and decision support documents and condition fact sheet, if needed) – Statement that the youth’s care is covered by pediatric practice until first visit– Offer to be a consultant as needed

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One Measurement Option

Initial Health Care Transition Assessment (Handout)

• Qualitative self-assessment tool • Provides a snapshot of where practice is in

implementing transition processes• New questions on consumer feedback and

leadership

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Core Element #1: Policy Level 1: Clinicians vary in their approach to health care transition,

including the appropriate age for transfer to adult providers Level 2: Clinicians follow a uniform but not a written policy about the

age for transfer. The approach for transition planning differs among clinicians.

Level 3: The practice has a written transition policy or approach, developed with input from youth and families that includes privacy and consent information and addresses the practice’s transition approach and age of transfer. The policy is not consistently shared with youth and families.

Level 4: The practice has a written transition policy or approach, developed with input from youth and families that includes privacy and consent information, a description of the practice’s approach to transition, and age of transfer. Clinicians discuss it with youth and

families beginning at ages 12 to 14. The policy is publicly posted and familiar to all staff.


#2: Tracking and Monitoring

Level 1: Clinicians vary in the identification of transitioning youth, but most wait until close to the age of transfer to identify and

prepare youth. Level 2: Clinicians vary in the identification of transitioning youth, but

most wait until close to the age of transfer to identify and prepare youth.

Level 3: The practice has an individual transition flow sheet or registry for identifying and tracking transitioning youth, ages 14 and older,

or a subgroup of youth with chronic conditions as they progress through and complete some but not all transition processes.

Level 4: The practice has an individual transition flow sheet or registry for identifying and tracking transitioning youth, ages 14 and older,

or a subgroup of youth with chronic conditions as they progress through and complete all “Six Core Elements of Health Care Transition 2.0,” using EHR if possible.


#3: Readiness Level 1: Clinicians vary in terms of the age when youth begin to have

time alone during preventive visits without the parent/caregiver present. Transition readiness is seldom assessed.

Level 2: Clinicians consistently offer time alone for youth after age 14 during preventive visits without the parent/caregiver

present. They usually wait to assess transition readiness/self- care skills close to the time of transfer.

Level 3: The practice consistently offers clinician time alone with youth after age 14 with clinicians during preventive visits, and

clinicians discuss transition readiness/self-care skills and changes in adult-centered care beginning at ages 14 to 16, but no formal assessment tool is used.

Level 4: The practice consistently offers clinician time alone with youth after age 14 during preventive visits. Clinicians use a

standardized transition readiness assessment tool. Self-care needs and goals are incorporated into the youth’s plan of care beginning at ages 14 to 16.


#4: Planning Level 1: Clinicians vary in addressing health care transition needs and goals.

They seldom make available a plan of care (including medical summary and emergency care plan and transition goals and action steps) or a list of adult providers.

Level 2: Clinicians consistently address transition needs and goals as part of the plan of care. They usually provide a list of adult providers close to the time of transfer.

Level 3: The practice partners with youth and families in developing and updating their plan of care with prioritized transition goals and preferences for securing an adult provider. This plan of care is regularly updated and accessible to youth and families.

Level 4: The practice has incorporated transition into its plan of care template for all patients. All clinicians are encouraged to partner with youth and families in developing transition goals and updating and sharing the plan of care. Clinicians address needs for decision-making supports prior to age 18. The practice has a vetted list of adult providers and assists youth in identifying adult providers.


#5: Transfer of Care Level 1: Clinicians usually send medical records to adult providers

in response to transitioning patient requests. Level 2: Clinicians consistently send medical records to adult

providers for their transitioning patients. Level 3: The practice sends a transfer package that includes the

plan of care (including the latest transition readiness assessment, transition goals/actions, medical summary and emergency care plan, and, if needed, legal documents, and a condition fact sheet).

Level 4: The practice sends a complete transfer package (including the latest transition readiness assessment, transition

goals/actions, medical summary and emergency care plan, and, if needed, legal documents, and a condition fact sheet), and pediatric clinicians communicate with adult clinicians, confirming pediatric provider’s responsibility for care until young adult is seen in the adult practice.


#6: Transfer Completion Level 1: Clinicians have no formal process for follow-up with

patients who have transferred to new adult providers. Level 2: Clinicians encourage patients to let them know

whether or not the transfer to new adult provider went smoothly.

Level 3: The pediatric practice communicates with the adult practice confirming completion of transfer/first appointment

and offering consultation assistance, if needed. Level 4: The practice confirms transfer completion, need for

consultation assistance, and elicits feedback from patients regarding the transition experience.


Second Measurement Option

Health Care Transition Process Measurement Tool• Objective scoring method with documentation

requirements• Measures implementation of Six Core Elements,

consumer feedback and leadership, and dissemination

• Intended to be conducted at start of QI initiative as baseline measure and repeated to assess progress

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Measurement Tool: Policy Example

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Summary of Latest Developments in Clinical and Measurement Tools

• Six Core Elements (2.0)– Side by Side Handout• 3 different packages – for patients leaving pediatric

care, staying with their same provider, and entering adult care

• Tools can be customized for your practice• Available measurement tools – qualitative and

scorable options and a consumer feedback survey

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What to do? Where to start?

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STARTING TRANSITION QI/PILOT IN PRIMARY, SPECIALTY, AND MANAGED CARE

Involve pediatric and adult practices, NOT pediatric only Gain leadership buy-in Involve parent, youth, and YA consumers Start as pilot using QI methods Measure progress Adapt and spread

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A Primary Care Example: DC

• Five large pediatric and adult academic primary care sites: Children’s National Medical Center’s adolescent clinic, CNMC’s Adams Morgan Clinic (mostly Latino), Georgetown’s adolescent clinic, Howard’s family medicine clinic, and GW’s internal medicine clinic

• Teams: lead physician, nurse/social worker care coordinator, and consumer• Transition population: Medicaid-insured youth with special health care

needs (all SSI-eligible and majority African American)• 5 one and half day learning sessions plus regular coaching calls and on-site

visits over 22 months (Feb. 2011-Dec. 2012) • Use of QI methods/PDSA cycles• Got Transition staff provided coaching

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Results from DC Transition Learning Collaborative

• All pediatric, family medicine, and internal medicine practices created practice-wide policies on transition

• A total of 400 youth and young adults included in pediatric transition registries and 128 in adult registries

• Transition readiness assessments conducted with patients in their registry: 88% in pediatric sites and 73% in adult sites

• Transition plans developed: 29% of youth and 32% of young adults

• 50 youth and young adults transferred to adult practices during last 6 months of LC -- with updated medical summary, transition readiness assessment, and a plan of care

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DC LC Pediatric and Adult Practices HCT Index Data

Average total score for each core element

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Lessons Learned From DC LC• Feasible to implement Six Core Elements with ready made adaptable tools• Involvement of pediatric, family medicine, and adult practices from outset

was key• Senior leadership (practice and department) engagement essential• Transition planning in early adolescence is much easier than transition

planning at ages 18 and older• Involvement of nursing, social work, and other clinic staff who are part of

clinic processes is critical• Engagement of consumers is important and challenging to maintain• Sustainability requires EHR integration and payment mechanisms- both are

currently being actively addressed by Got Transition • A variety of care transfer models evolved depending on the availability of

adult subspecialty care for specific pediatric-onset diseases

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A Subspecialty Transition Example: U. Rochester (NY)

• Department of Pediatrics identified transition as a top issue across all subspecialty divisions

• Chair appointed “transition task force” to facilitate this process, led by Dr. Brett Robbins– Centered in division of adolescent medicine– Strong representation of combined Med-Peds trained faculty

• Key stakeholders identified for committee– Enlisted the support of the Chair of Medicine– Access to division chief meetings in both IM and Peds– Chose 6 core elements as template for QI process

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Subspecialty Transition

• Pediatric and Internal Medicine divisions initially completed a baseline Current Assessment of Health Care Transition Activities

• Selected 3 pediatric-medicine subspecialty dyads based on interest and disease process– Endocrine (DM), Hematology (SS) , pulmonary (CF)– All 6 completed a baseline HCT Process Measurement Tool– All 6 selected 1-2 representatives (MD, SW, NP)

• Monthly Meetings between ped and im division reps• QI process with many PDSA cycles• Goal of incorporating 6 core elements into process


Themes at Start-up

• Completing Current Assessment of HCT at start was itself an intervention

• Low level of explicit transition policies and transition practices

• Peds: not energetic about process• IM: Confused but willing• Neither involving patients and families• Neither “knew what they didn’t know” about the

transition process


Subspecialty TransitionLessons Learned

• Low level of baseline transition work or even awareness among all IM and Peds subspecialties

• Most work in QI process done by SW, NP• Peds had many misperceptions of IM• Peds had a very hard time letting go• IM not prepared, but eager to learn• Sometimes hard to find willing IM provider• Need buy-in from chairs and division chiefs• Need lots of IT support, but don’t get lost in the computers• Moderator with credibility in both departments is very helpful• Policies and assessments come far easier than trust and implementation


A Medicaid Managed Care Example: DC

• Why are health plans interested in pediatric to adult transition?– Ensure continuity of care and improve self-care,

particularly among those with chronic conditions– Retain young adults as health plan members– Improve satisfaction among young adults (often among the

most dissatisfied health care consumers)– Comply with PCMH certification standards– Reduce unnecessary ED visits/hospitalization

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Health Services for Children with Special Needs (HSCSN): A DC MCO

• Serves 6,000 Medicaid enrollees from birth to age 26, all with SSI-eligible conditions

• Analysis of HSCSN utilization data revealed:– A sizeable proportion of young adults over age 22 still being seen by

pediatric providers.– Approximately two-thirds of 18-21 year olds with chronic conditions

cared for by pediatric PCPs and will need to transfer to adult care in the next few years.

– A large proportion of young adults are not using primary care, especially those with developmental disabilities, but using ER


Service Utilization Profile of HSCSN Members, Ages 18-26, in 2013

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Pilot Transition Intervention• Several senior leadership meetings to gain buy-in and health plan context

(eg, ongoing care planning, QI processes, insurance transition planning)• Series of meetings with senior nurse care management staff to review and

customize each core element and obtain final review by medical director and CEO

• Next piloted the customized 6 core elements with small group of enrollees and pediatric and adult practices

• Defined roles of HSCSN, provider practices, and Got Transition• Designation of single nurse care manager and AmeriCorps volunteer to

implement pilot project within health plan• Invitation and education of pediatric and adult practices (lunch & learn)• Invitation and active outreach to engage young adults• Weekly updating, transition mentoring, and trouble-shooting calls with

HSCSN and Dr. White (Got Transition)

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Customized Six Core Elements • Health care transition policy (customized)• Tracking spreadsheet (customized)• Readiness assessment (customized)

– Insurance question added• Integrated transition plan (customized)• Plan of care (customized)• Medical summary and emergency care plan• Transfer checklist• Welcome & orientation of new young adult • Feedback survey (for young adult & family/caregiver)

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HSCSN Pilot Project

• 49 HSCSN members– ages 18-25– SSI-eligible diagnostic groups: mental health,

intellectual/developmental disability, and complex medical– 35 agreed to participate; 14 members discontinued

participating– Range of case management complexity levels

• Practices: 3 pediatric and 1 adult site in DC

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Key Results of Transition Pilot

• Over 80% of pilot group received recommended 6 core elements in 6 months

• Based on readiness assessment results, only 50% of YAs knew their medical needs, could explain these needs to others, and knew about privacy changes at age 18. Almost 80% reported needing to learn to call for their own doctor visits

• Completion of transfer among those 18 and older was very difficult, primarily because of problems engaging YA

• Using Got Transition’s Current Assessment of HCT: HSCSN scored at level 1 at start; 6 months later: level 3 for each core element. To get to level 4, spread is required.

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Lessons Learned• The Six Core Elements can be implemented/customized into a managed

care plan’s processes • Transition process should begin before age 18, preferably around ages 12-

14, while the youth and family are regularly using health services and engaged in their health

• Important to delineate roles of managed care staff and pediatric and adult health care providers, but SHARED role preferred by clinicians

• Need for plan to proactively identify adult PCPs willing to treat young adults with mental health, ID/DD, and complex medical conditions; communicate these PCP choices to young adult members; and encourage adult practices to provide welcome information for their new young adult members

• Managed care plans need to consider using financial incentives to gain more traction

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Summary of Primary, Specialty, and Managed Care Transition QI Examples

• Feasible to adapt and implement Six Core Elements in primary, specialty and managed care

• Starting as a pilot important• Involvement of pediatric and adult leadership and teams is

key• Everyone is at the same starting point- Level 1• Implementation takes more than writing a policy and doing a

readiness assessment• Progress is rewarding and sustainable

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Payment for Transition

• See handout, Coding and Reimbursement Tip Sheet for Transition

• Developed by Got Transition with the AAP• Describes a set of innovative payment

strategies• Provides a comprehensive list of CPT codes

and Medicare values

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Options for Enhanced Fee-For-Service Payments

• Reimburse at higher fees – eg, for office visits before and after transfer

• Recognize codes previously not paid for -- eg, care plan oversight, telephone calls

• Even if providers don’t recognize these codes, it is still important to code for the service

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Options for Pay for Performance

• Tie bonuses for pediatric and adult provider transition efforts together. For example, – Transfer before age 22 with current medical information

and evidence of communication with adult providers + first adult PCP visit within 6 months of last pediatric visit and evidence of orientation/welcome to new young adult

• Offer bonus to adult providers for taking certain volume of young adults with chronic conditions

• Tie P4P to improvements made or scores received on Got Transition measurement tools

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Options for Capitation

• Offer monthly care coordination payments to added time:– in preparing youth/family for transfer, – preparing the necessary transfer documents,– ensuring coordination and communication

between pediatric and adult systems, and– implementing outreach and follow-up strategies

for new young adult patients• Consider adjusting for complexity of patients

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Options for Bundled Payments

• Package of transfer and new patient services:– Face to face visits– Updating medical summary, readiness assessment, plan of

care– Communication between providers– Assessment of treatment and medication of new patients– Identification of adult specialists

• CPT code for transitional care management services only for hospital to home/community settings

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Option for Shared Savings

• Savings from reduced emergency room and hospitalization could be shared with participating pediatric and adult providers

• Structural and quality standards from Got Transition could be used

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Options for Administrative or Infrastructure Payments

• Options used in Medicare (EHR) and Medicaid (to implement state Medicaid plan)

• Could be used to customize EHR to incorporate 6 core elements

• Or for transition training of pediatric and adult providers

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Summary of Payment Options

• Many options available to serve as financial incentives

• Just need to get the payers to the table• Got Transition, in near future, will put out a

crosswalk for billing for Six Core Elements• We are also reaching out to Medicaid MCOs and

commercial health plans to inform them of Six Core Elements and to encourage their payment support for transition delivery improvements

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Youth and Family Resources



Presentation Learning Objectives1. Understand latest developments in clinical and measurement

tools for transition from pediatric to adult health care. 2. Review examples of QI strategies to incorporate transition

core elements into 3 types of practices/systems: academic primary care settings, academic subspecialty clinics, and a Medicaid managed care plan.

3. Identify innovative payment strategies for transition.4. Learn about new health care transition resources for youth

and families.

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Thank You and [email protected]

Please visit www.GotTransition.org

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http://www.gottransition.org/

Documents

CENTER FOR HEALTH CARE TRANSITION IMPROVEMENT IMPLEMENTATION AND EVALUATION OF TRANSITION QUALITY IMPROVEMENTS IN PEDIATRIC AND ADULT SETTINGS Peggy McManus,