Kimberly Major, MSW IIChristine Hoehner, NP

February 23, 2018

Transition is the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-centered health care systems.

Successful Transition: Young adult, family, health care system must collaborate in support of building skills for positive disease self-management and independent living.

1. Transition Policy

2. Transition Tracking and Monitoring

3. Transition Readiness

4. Transition Planning

5. Transfer of Care

6. Transfer Completion

http://www.gottransition.org/providers/index.cfm

Provide care that is: *Uninterrupted

*Patient-centered

*Flexible

*Comprehensive

*Developmentally appropriate

Equip youth with tools to assist in navigating the adult healthcare systems.

Skill building for positive disease self management and independent living.

Multidisciplinary collaboration

Early identification of patients

Transitional planning

Patient/family engagement

Transfer of information

Early: Starts around age

12. Patients provided with Transition Brochure.

Age appropriate discussion about medical care that includes, medications, tests and treatments.

Starting around age 12, adolescent visits include seeing provider alone.

Discuss the transition age 18-21.

Middle: Annual assessment

of Transition Readiness starts at age 15

Know your medical conditions, medications and why taking medications.

Open communication to discuss parent or caregiver concerns.

Learn how the insurance plan (s) works.

Continue transition discussion.

• Late: around18-21 years

• Older adolescents should order medication refills/call to schedule clinic appointments.

• Visit the adult hospital in advance.

• Fill out GHPP insurance paperwork prior to 21st

birthday.

• Attend Transition Workshop/Graduation.

Transition Readiness Assessment (Transition Intervention Program- Readiness for Transition (TIP –RFT)

Health Care SkillsEducation and Vocation SkillsHealth BenefitsSocial SupportIndependent LivingFeelings about TransitionSickle Cell StressSickle Cell Self-EfficacyMental Health Screening

Pediatric providers must Adult providers must

• Evaluate transition readiness goals at least annually & increase interactions until they are reached.

• Identify available and qualified adult care providers along with family.

• Ensure appropriate communication of any and all medical needs to receiving provider.

Optimize patients’ self-management skills by providing support through care coordination and consultation.

Be sensitive and responsive to needs and challenges of young adults with SCD in transition.

Invited 12 patients ages 21-26

Workshop focused on 8 core competencies:

1. Health benefits

2. Feelings and stress management

3. Health system navigation

4. Independent living

5. Pain management

6. Education

7. Vocation

8. Basic pathophysiology of SCD

Utilized providers with specific knowledge to present workshop modules.

Sickle cell clinicians attended workshop to answer questions from patient’s and parents.

Healthier outcomes for individuals with SCD may be achieved by supporting coordination of care of pediatric to adult centered facilities.

Intentional linkages between patients and families, and pediatric and adult clinicians reduce harm of systems barriers and challenges.