Transition for Youth from Pediatrics to Adult Systems of Care:What is Different in 2012?

Transition to Adult Care SymposiumBoston, MA

April 27, 2012

Richard C. Antonelli, MD, MSAssistant Professor of Pediatrics

Medical Director of Integrated Care

Speaking of Transition…

Transition 2005

• Transition– You mean from hospital to nursing home?

• Consensus Statement (2002)

• Find adult providers willing to care of these youth– Rotate– Buy them gifts

Transition 2011

• New Consensus Statement with algorithm

• Increasing collaborations between pediatric and adult provider organizations

• Increasing interest from academia

• Development and promulgation of tools

Transition 2012

• ACA– Eligibility for insurance

• Triple Aim

• Value Optimization– Quality– Cost

What Do We Currently Measure?

For CYSHCN, age 12‐17 years only:

1. The youth’s doctor has discussed each of the following

with him/her (or parent indicated that such discussions

were not needed):

- Transitioning to doctors who treat adults

- Changing health needs as youth becomes an adult

- How to maintain health insurance as an adult

2. Doctor usually or always encourages the youth to take

age‐appropriate responsibility for managing his or

her own health needs

Measure endorsed by the National Quality Forum (NQF)

How Much Progress Are We Making?Or, Why Aren’t We?

www.childhealthdata.org

Impact by Type of Special Needs

Impact of Emotional, DB Issues

Role of Medical Home

Disparities

Opportunities

• Identify patients meeting criteria for care coordination– Medical Home Matters

• PCP-based• Subspecialty-based

– Collaborative Care Models• Care Coordination• Case management

– Look for ways to reduce costs• Unplanned readmissions• ED utilization for ambulatory sensitive conditions• Population-based approach

Relationships

• Vocation• Education

• Adult• Pediatrics

PCP PCP

SPSP

Youth, Family, “Circle of Support”

Example

• Population: Patients w/ sickle cell disease

• Outcomes to drive value– QoL– Graduation rates– Employment status– Cost by sector

• Activities which support Care Coordination (CCMT)

ED Imaging

In-patient Ambulatory

Pharmacy PCP and SP

Patient with Sickle Cell Disease in Transition

• Define “Episode of Care”

• Time-Related– Service provision from 18th to 19th birthday

• Preventive services – care guidelines• Episodic services – evidence-based• Patient-focused education

• Financing– bundled; pmpm; FFS; global– Care Coordination– Risk adjustment

What Must We Do Right Now?

• Focus on Optimizing Value– Identify and track clinical outcome measures

• Condition-specific• Process and structure measures are NOT sufficient

• Create innovative, sustainable models of collaborative care– Focus on co-management and TME

• Short and longer term savings critical• ACO structure

– Define the population– Attribution may be challenge– or opportunity