Advancing healthcare transitions in the medical home: tools for providers, families and adolescents with special healthcare needs

Transition for adolescents with learning disabilities and an immunodeficiency

Many adolescents with immunodeficiency are diagnosed with a comorbid learning disability. The process of transition from paediatric to adult healthcare for these individuals occurs with a range of additional challenges. Due to the lack research available on immunodeficiency specifically, this article addresses a number of recommendations from the research undertaken with individuals with other chronic health conditions and learning disability. The research suggests that for individuals with learning disabilities autonomy and independence needs to be acknowledged despite their perceived need for increased input from parents and medical professionals. Instead, medical professionals could prioritise their relationship with the adolescent patient by ensuring communication needs are met and that a sense of continuity between paediatric and adult services is maintained. Families can be supported through psychological interventions which provide skills to allow family members to empower their young adult with a learning disability. Specific tools to help the transition process run more smoothly are also recommended and have proven to be effective in other parts of the world.

Hospital emergency department visits made by developmentally disabled adolescents with oral complications

Purpose

We used Andersen's Behavioral Model in a cross-sectional study to determine the factors associated with utilization of the emergency department (ED), controlling for whether an adolescent has a developmental disability (DD) and one or more oral complications (toothaches, decayed teeth, bleeding gums, eating or swallowing problems).

Methods

Data from the 2016–2019 National Survey of Children's Health (NSCH) was used for this secondary data analysis study. We used frequencies and percentages to describe the sample characteristics. Chi-square tests were used for bivariate analyses. Multivariable logistic regression modeling was conducted to predict ED visits by adolescents aged 10–17 controlling for predisposing, enabling, and need variables.

Results

The sample consisted of 68,942 adolescents who were primarily male, non-Hispanic White, and born in the U.S. Parents reported that 69% of the adolescents had neither a DD nor an oral complication; 10% had no DD but experienced one or more oral complication; 16% had a DD but no oral complication; and 5% had both DDs and one or more oral complication. Adolescents with both a DD and an oral complication reported the highest level of ED visits at 33%, compared to 14% of adolescents with neither DD nor oral complication. Regression analysis showed that adolescents with a DD and oral complication (OR: 2.0, 95% CI: 1.64–2.54, p < 0.0001), and those with DDs but no oral complications (OR: 1.45, 95% CI: 1.25–1.68, p < 0.0001) were at higher odds of having an ED visit compared to those with neither a DD nor an oral complication. Not having a Medical Home increased the likelihood of ED visits by 14% (p = 0.02). Those with private insurance (OR: 0.63, 95% CI: 0.53–0.75, p < 0.0001) and those from a family where the highest level of education was some college and above (OR: 0.85, 95% CI: 0.73–0.98, p = 0.03) were less likely than their counterparts to have had an ED visit.

Conclusion

Adolescents with DDs and oral complications utilize ED visits more frequently than those with neither DDs nor oral complications. Integrating the dental and medical health systems and incorporating concepts of a Patient-Centered Medical Home could improve overall health care and reduce ED visits for adolescents.

Trends and Disparities in Health Care Transition Preparation from 2016 to 2019: Findings from the US National Survey of Children's Health

OBJECTIVES

To evaluate national trends in health care transition preparation over a 4-year period using the National Survey of Children's Health (NSCH) and to identify and examine disparities in receipt of health care transition preparation over the study period.

STUDY DESIGN

Data from the NSCH, an annual serial cross-sectional survey conducted from 2016 to 2019, were examined. Caregivers answered questions regarding one of their children within each of a random sample of households across the US. The primary analysis examined trends in health care transition preparation based on the year of survey completion. A secondary analysis examined the associations of race/ethnicity, primary household language, insurance type, and children with special health care needs (CSHCN) with receipt of health care transition preparation.

RESULTS

We included data from 54 434 youths (20 708 in 2016, 8909 in 2017, 12 587 in 2018, and 12 230 in 2019) aged 12-17 years whose caregivers completed the NSCH between 2016 and 2019. The sample was weighted to be nationally representative based on weights provided by the NSCH. The proportion of youths receiving necessary health care transition preparation increased over the study period, from 14.8% in 2016 to 20.5% in 2019 (P < .001). Multivariable logistic regression demonstrated increased odds of receiving health care transition preparation in 2018 and 2019, as well as for White non-Hispanic youths, those with English or Spanish as a primary household language, those with private insurance, and CSHCN.

CONCLUSIONS

Although the proportion of youths receiving health care transition preparation has increased since 2016, the need for ongoing improvement and elimination of disparities in health care transition preparation remains.

A Typology of Transition Readiness for Adolescents with Congenital Heart Disease in Preparation for Transfer from Pediatric to Adult Care

PURPOSE

To understand the effectiveness of a nurse-led transition intervention by analyzing qualitative data generated in the context of a clinical trial.

DESIGN & METHODS

Qualitative study of a two-session transition intervention conducted by registered nurses at two sites. Adolescents aged 16-17 years with moderate or complex congenital heart disease (CHD) had been randomized to a two-session transition intervention or usual care. Session 1 emphasized patient education including creation of a health passport and goal setting. Session 2, two months later, emphasized self-management. Qualitative data extracted from intervention logs, field notes and audio recordings of the sessions were analyzed for content and themes.

RESULTS

Data from 111 transition intervention sessions with 57 adolescents were analyzed. Creating a health passport, goal setting, and role-plays were the elements of the intervention most valued by participants. A typology of transition readiness was identified: 1) the independent adolescent (5%), already managing their own care; 2) the ready adolescent who was prepared for transition after completing the intervention (46%); 3) the follow-up needed adolescent who was still in need of extra coaching (26%), and 4) the at-risk adolescent who warranted immediate follow-up (14%). Baseline knowledge and transition surveys scores validated the typology.

CONCLUSIONS

A two-session nursing intervention met the transition needs of approximately half of adolescents with CHD. However, additional transition-focused care was needed by 40% of participants (groups 3 and 4).

PRACTICE IMPLICATIONS

These findings will guide pediatric nurses and other healthcare professionals to optimize an individualized approach for ensuring transition readiness for adolescents with CHD.

Strategies for improving primary care for adolescents and young adults transitioning from pediatric services: perspectives of Canadian primary health care professionals

BACKGROUND

Family physicians and other members of the primary health care (PHC) team may be ideally positioned to provide transition care to adolescents and young adults (AYAs; aged 12-25 years) exiting pediatric specialty services. Potential solutions to well-known challenges associated with integrating PHC and specialty care need to be explored.

OBJECTIVE

To identify strategies to transition care by PHC professionals for AYAs with chronic conditions transitioning from pediatric to adult-oriented care.

METHODS

Participants were recruited from six Primary Care Networks in Calgary, Alberta. A total of 18 semi-structured individual interviews were completed, and transcribed verbatim. Data were analyzed using a qualitative description approach, involving thematic analysis.

RESULTS

Participants offered a range of strategies for supporting AYAs with chronic conditions. Our analysis resulted in three overarching themes: (i) educating AYAs, families, and providers about the critical role of primary care; (ii) adapting existing primary care supports for AYAs and (iii) designing new tools or primary care practices for transition care.

CONCLUSIONS

Ongoing and continuous primary care is important for AYAs involved with specialty pediatric services. Participants highlighted a need to educate AYAs, families and providers about the critical role of PHC. Solutions to improve collaboration between PHC and pediatric specialist providers would benefit from additional perspectives from providers, AYAs and families. These findings will inform the development of a primary care-based intervention to improve transitional care.

Moving on: How to switch young people with chronic intestinal failure from pediatric to adult care. a position statement by italian society of gastroenterology and hepatology and nutrition (SIGENP) and italian society of artificial nutrition and metabolism (SINPE)

In 2019 the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) and the Italian Society of Artificial Nutrition and Metabolism (SINPE) created a joint panel of experts with the aim of preparing an official statement on transition in Chronic Intestinal Failure (CIF). The transition from pediatric to adult care has a key role in managing all chronic diseases and in optimizing the compliance to care. Thus SIGENP and SINPE, in light of the growing number of patients with IF who need long-term Parenteral Nutrition (PN) and multidisciplinary rehabilitation programs throughout adulthood, shared a common protocol to provide an accurate and timely process of transition from pediatric to adult centers for CIF. The main objectives of the transition process for CIF can be summarized as the so-called "acronym of the 5 M": 1)Motivate independent choices which are characteristics of the adult world; 2)Move towards adult goals (e.g. self-management of his pathology and sexual issues); 3)Maintain the habitual mode of care; 4) Minimize the difficulties involved in the transition process and 5)Modulate the length of the transition so as to fully share with the adult's team the children's peculiarities.

Demographics and baseline care among newly transitioning adult congenital urology patients

INTRODUCTION

In 2017, UCSF established a formal Transitional Urology (TU) clinic co-run by pediatric and adult urology aimed at providing comprehensive urologic care for people progressing into adulthood with complex urologic histories.

OBJECTIVE

We aim to describe baseline demographic and disease characteristics of this population, understand gaps in care, and gauge follow-through.

STUDY DESIGN

We performed a retrospective chart review of all new patients in the TU clinic at UCSF from February 2017 through January 2019. After approval from an institutional review board, demographic and clinical data were collected from medical records.

RESULTS

39 new patients were seen in UCSF's TU clinic during a 23-month period. Our cohort included 20 patients with spina bifida and neurogenic bladder, 5 with bladder exstrophy, 3 with disorders of sexual development (DSD), 5 with obstructive uropathy, 2 with cloacal anomalies, and 1 patient each with calcinuria, reflux nephropathy, prune belly syndrome, and urachal cyst. Mean age of patients was 26 years, 63% were male, 88% spoke English, and 70% had public insurance. Patients lived an average of 94 miles from the clinic and had a mean zipcode-based household income of $70,110. There was an average of 19 months between the initial TU visit and the most recent prior urology visit. The median time since last creatinine as well as last renal ultrasound was 9 months. 19 (54%) patients warranted a total of 28 referrals to other providers at their initial visit, and 42% of these were obtained within 6 months.

DISCUSSION

According to our demographic data, TU patients are likely to have public insurance, live far from the TU clinic, and come from low SES backgrounds. At initial presentation over half of patients warranted updated tests like creatinine and renal ultrasound. Furthermore, nearly two-thirds of patients required at least one referral to a different provider, suggesting a majority of these patients had unmet medical needs at the time of presentation to the TU clinic.

CONCLUSION

Our data indicate that new patients to the TU clinic often warrant additional workup, updated testing, and referrals to sub-specialty care as these needs are often unmet at the time of presentation. The etiology of this is unclear and it may be due to insurance difficulties, inability to identify an appropriate adult subspecialty provider or access to care issues. Further investigation into barriers to implementation of transitional care is needed to provide comprehensive management to this challenging patient population.

Implementation of a Portable Medical Summary for Adolescents and Young Adults With Medical Complexity in Transition to Adult Health Care

BACKGROUND

Adolescents and young adults (AYA) with special health care needs are living into adulthood, as improvements in care increase the likelihood of survival. Fewer than half have the resources needed to transition to adult care (McPheeters et al., 2014). A portable medical summary is a concise document summarizing current medical information about a patient that can be used across healthcare systems as AYA transition to adult care. Though a consensus statement recommending the use of such a summary has existed for over a decade (American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians-American Society of Internal Medicine (ACP-ASIM), 2002), little progress had been made in the development of a portable medical summary.

METHODS

The Institute for Healthcare Improvement (IHI) Model was used to implement a process to provide a portable medical summary to AYAs with medically complex conditions (Institute for Healthcare Improvement, 2017).

INTERVENTIONS

The tool was developed using the electronic health record and shared with families. Feedback from care providers and families led to modifications to improve its usefulness and feasibility. Implementation of the process was tested for four months.

RESULTS

The number of AYA, ages 16-24, who were being seen for well care or chronic care management visits, and had a portable medical summary initiated, had increased from 0% to 100%.

CONCLUSIONS

The use of a PMS that summarizes medical care received in the pediatric system, is one tool that may be used to bridge the gap between pediatric and adult care.

Care of girls and women with Turner syndrome: beyond growth and hormones

Turner syndrome (TS), although considered a rare disease, is the most common sex chromosome abnormality in women, with an incident of 1 in 2500 female births. TS is characterized by distinctive physical features such as short stature, ovarian dysgenesis, an increased risk for heart and renal defects as well as a specific cognitive and psychosocial phenotype. Given the complexity of the condition, patients face manifold difficulties which increase over the lifespan. Furthermore, failures during the transitional phase to adult care result in moderate health outcomes and decreased quality of life. Guidelines on the optimal screening procedures and medical treatment are easy to find. However, recommendations for the treatment of the incriminating psychosocial aspects in TS are scarce. In this work, we first reviewed the literature on the cognitive and psychosocial development of girls with TS compared with normal development, from disclosure to young adulthood, and then introduce a psychosocial approach to counseling and treating patients with TS, including recommendations for age-appropriate psychological diagnostics. With this work, we aim to facilitate the integration of emphasized psychosocial care in state-of-the-art treatment for girls and women with TS.

Health Care Transitions for Adolescents and Young Adults With Special Health Care Needs: Where Are We Now?

Eventually, all adolescents must "graduate" from pediatric-oriented to adult-oriented health care. This transition, most often occurring during young adulthood, is especially important for adolescents with special health care needs and involves not only primary care physicians, but also both pediatric and adult subspecialists. Several studies support the benefit of transitional programs for adolescents and young adults with special health care needs. Additionally, the American Academy of Pediatrics named transitional care as one of its top priorities. However, transitional programs have yet to become an established norm among hospitals and providers, specifically outside of children's hospitals. This topic synopsis aims to draw attention to this important issue, review the rationale behind current recommendations and report the current status of transitional programs in North America. Moreover, the steps that individual clinicians, practices and health systems may take to plan for successful health care transitions are discussed.

The neurologist's role in supporting transition to adult health care: A consensus statement

The child neurologist has a critical role in planning and coordinating the successful transition from the pediatric to adult health care system for youth with neurologic conditions. Leadership in appropriately planning a youth's transition and in care coordination among health care, educational, vocational, and community services providers may assist in preventing gaps in care, delayed entry into the adult care system, and/or health crises for their adolescent patients. Youth whose neurologic conditions result in cognitive or physical disability and their families may need additional support during this transition, given the legal and financial considerations that may be required. Eight common principles that define the child neurologist's role in a successful transition process have been outlined by a multidisciplinary panel convened by the Child Neurology Foundation are introduced and described. The authors of this consensus statement recognize the current paucity of evidence for successful transition models and outline areas for future consideration.

Pediatricians Transitioning Practices, Youth With Special Health Care Needs in New York State

OBJECTIVE

To assess current practices of New York State pediatricians as they transition youth with special health care needs to adult-oriented medical care.

METHODS

A survey of New York State pediatricians included 6 critical steps from 2002 consensus statement, 11 essential steps adapted from recent literature, and questions targeting age of starting transition and availability of transition policy.

RESULTS

Of 181 respondents, only 11% have a transition policy. Most assist patients in transition process; identify an adult provider (92%); and create portable medical summary (57%). Only 3% start planning process at recommended age. No respondents are compliant with all 6 critical steps; subspecialists were more likely to report compliance to more than 4 steps.

CONCLUSIONS

Participating pediatricians are making gains, yet effort is needed, to incorporate the essential steps into practice for transitioning youth with special health care needs. Recognition of barriers, use of electronic tools, and clarifying subspecialist's approach, may improve compliance with transition recommendations.

Multidisciplinary Support for Healthcare Transitioning Across an Urban Healthcare Network

BACKGROUND

A successful transition from pediatric to adult oriented health care is a vital process in maintaining a patient-centered medical home for youth with special health care needs (YSHCNs). We assessed practices of pediatric providers who transition YSCHNs to adult-oriented medical care in a large urban academic healthcare network.

METHODS

A cross-sectional Web-based survey was distributed to 376 generalist and subspecialist pediatric providers. Survey assessed provider-reported utilization of 11 Essential Steps adapted from the 2002 Consensus Statement on Health Care Transitions for YSHCNs, and recent transitioning literature. Compliance score (CS11) was calculated as a sum of steps completed. Additional items assessed knowledge of transitioning literature and respondent demographics.

RESULTS

Survey achieved a 28% response rate (n=105), of whom 84 reported assisting transitioning YSHCNs. Only 16.7% of these respondents were compliant with 7 or more of the 11 Essential Steps. Respondents who identified social work or nursing were more likely to have CS11 scores ≥7 compared to those without and were more likely to be compliant with specific steps.

CONCLUSION

We found limited and incomplete utilization of recommended transitioning steps for YSHCNs by pediatric providers within a large urban healthcare network. Access to support from social work and nursing was associated with greater utilization of specific recommended steps, and with more optimal compliance. Further research needs to assess the transitioning practices of all members of the multidisciplinary team and whether operationalizing healthcare transition for YSHCNs as a multidisciplinary activity impacts the transitioning process and patient outcomes.

College health service capacity to support youth with chronic medical conditions

BACKGROUND AND OBJECTIVE

Twenty percent of US youth have a chronic medical condition and many attend college. Guidelines for transition from pediatric to adult care do not address college health services, and little is known about their capacity to identify, support, and provide care for these youth. The objective of this study was to describe college health center policies, practices, and resources for youth with chronic medical conditions (YCMC).

METHODS

Survey of medical directors from health centers of a representative sample of 200 4-year US colleges with ≥ 400 enrolled undergraduate students. Patterns of identification, management, and support for youth with a general chronic medical condition and with asthma, diabetes, and depression, were investigated; χ(2) and Fisher exact tests were used to ascertain differences by institutional demographics.

RESULTS

Directors at 153 institutions completed the survey (76.5% response rate). Overall, 42% of schools had no system to identify YCMC. However, almost a third (31%) did identify and add to a registry of incoming YCMC on review of medical history, more likely in private (P < .001) and small (<5000 students, P = .002) colleges; 24% of health centers contacted YCMC to check-in/make initial appointments. Most institutions could manage asthma and depression (83% and 69%, respectively); 51% could manage diabetes on campus.

CONCLUSIONS

Relatively few US colleges have health systems to identify and contact YCMC, although many centers have capacity to provide primary care and management of some conditions. Guidelines for transition should address policy and practices for pediatricians and colleges to enhance comanagement of affected youth.

Ready, set, stop: mismatch between self-care beliefs, transition readiness skills, and transition planning among adolescents, young adults, and parents

Health care transition (HCT) from pediatric to adult-focused systems is a key milestone for youth. Developing self-care skills and HCT planning are key elements. In a survey at 4 pediatric specialty clinics to 79 youth aged 16 to 25 years and 52 parents, skill-based HCT readiness was assessed using the Transition Readiness Assessment Questionnaire (TRAQ). Multivariable logistic regression evaluated the association between TRAQ scores and self-care beliefs. In all, 70% of youth and 67% of parents believed that they/their child could manage their care. Only 38% of youth and 53% of parents reported thinking about HCT; only 18% of youth and 27% of parents reported having a HCT plan. Youth with higher TRAQ scores were more likely to believe they could manage their care, controlling for age and gender (adjusted odds ratio = 4.0, 95% confidence interval = 1.7-9.5). Transition readiness skills are associated with self-care beliefs. However, a mismatch exists between high reported self-care beliefs and low levels of transition planning.

Hypertension awareness and control among young adults in the national longitudinal study of adolescent health

BACKGROUND

Young adults are less likely than older adults to be aware they have hypertension or to be treated for hypertension.

OBJECTIVE

To describe rates of hypertension awareness and control in a cohort of young adults and understand the impact of health insurance, utilization of preventive care, and self-perception of health on rates of hypertension awareness and control in this age group.

DESIGN AND PARTICIPANTS

Cross-sectional study of 13,512 young adults participating in Wave IV of the National Longitudinal Study of Adolescent Health in 2007-2008.

MAIN MEASURES

We defined hypertension as an average of two measured systolic blood pressures (SBP) ≥ 140 mmHg, diastolic blood pressures (DBP) ≥ 90 mmHg, or self-report of hypertension. We defined hypertension awareness as reporting having been told by a health care provider that one had high blood pressure, and assessed awareness among those with uncontrolled hypertension. We considered those aware of having hypertension controlled if their average measured SBP was < 140 mmHg and DBP was < 90 mmHg.

KEY RESULTS

Of the 3,303 young adults with hypertension, 2,531 (76%) were uncontrolled, and 1,893 (75%) of those with uncontrolled hypertension were unaware they had hypertension. After adjustment for age, sex, race/ethnicity, weight status, income, education, alcohol and tobacco use, young adults with uncontrolled hypertension who had (vs. didn't have) routine preventive care in the past 2 years were 2.4 times more likely (95% confidence interval [CI] 1.68-3.55) to be aware, but young adults who believed they were in excellent (vs. less than excellent) health were 64% less likely to be aware they had hypertension (OR 0.36, 95% CI 0.23-0.57). Neither preventive care utilization nor self-rated health was associated with blood pressure control.

CONCLUSIONS

In this nationally representative group of young adults, rates of hypertension awareness and control were low. Efforts to increase detection of hypertension must address young adults' access to preventive care and perception of their need for care.

Transition from pediatric to adult care in sickle cell disease: perspectives on the family role

Transition from pediatric to adult care poses challenges for adolescents with sickle cell disease (SCD). This study explored the transition perspectives of adolescents with SCD, their siblings, and caregivers. Focus groups were conducted with 12 African American families. Adolescents, siblings, and caregivers demonstrated awareness of transition and need for disease management responsibility. Siblings' and caregivers' concerns included adolescent medication adherence. Family concerns included leaving the pediatric environment and adult providers' lack of knowledge. Families recommended more transition preparation opportunities. Family members' perspectives are valuable in informing transition planning. Family-focused interventions designed to prepare and support families during transition are necessary.

Medical device design for adolescent adherence and developmental goals: a case study of a cystic fibrosis physiotherapy device

PURPOSE

This study investigates the psychosocial aspects of adolescent medical device use and the impact on adolescent adherence and goals for the transitional years between child and adulthood.

PATIENTS AND METHODS

Interviews were carried out with 20 adolescents with cystic fibrosis, investigating adolescent medical device use and experiences in relation to their personal and social lives and development through the adolescent years. The qualitative dataset was thematically examined using a content analysis method.

RESULTS

The results show that adolescent users of medical technologies want their independence and capabilities to be respected. Adolescent adherence to medical device use was associated with short- and long-term motivations, where older adolescents were able to comprehend the longer-term benefits of use against short-term inconvenience more acutely than younger adolescents. It was suggested that medical devices could provide a tool for communication with families and clinicians and could support adolescents as they take responsibility for managing their condition. Themes of "fitting into teenage life" and "use in the community" were associated with adolescents' needs to form their own identity and have autonomy.

CONCLUSION

This study shows that adolescent needs regarding medical device use are complex. It provides evidence to suggest that devices designed inclusively for adolescents may lead to improved adherence and also facilitate transition through the adolescent years and achievement of adolescent goals.