Youth Health Transition Quality Improvement Grant Guidance Wisconsin Children and Youth with Special Health Care Needs

Transcription

1 Youth Health Transition Quality Improvement Grant Guidance Wisconsin Children and Youth with Special Health Care Needs Thank you for your interest in the Wisconsin Youth Health Transition Quality Improvement (QI) Grant opportunity. The Youth Health Transition Initiative (YHTI) at the University of Wisconsin-Madison Waisman Center is releasing this Request for Proposals (RFP) to support implementation of health care transition quality improvement processes at the practice level. Based on available funds, up to five grants of up to $20,000 each will be offered. Support for the QI grants is provided to the YHTI through a grant from the Wisconsin Department of Health Services, Division of Public Health, Bureau of Community Health Promotion, Family Health Section, Children and Youth with Special Health Care Needs (CYSHCN) Program. The YHTI staff will provide support and technical assistance for the grantees. CRITICAL DATES September 19, 2016 Grant guidance released October 4, 2016: Grant Information Call, 1:45pm 2:30pm November 4, 2016: Applications due electronically (must submit application online using SurveyMonkey link): December 9, 2016: Award notifications released January 1, 2017: Practice teams begin grant work February 7, April 12, June 14, and August 9, 2017: Learning Community Calls, 12pm 1pm November 14, 2017: Attend all-day grantee meeting (tentative), location TBD December 31, 2017: Project completion January 31, 2018: Final project report due BACKGROUND INFORMATION Youth health transition is the process of moving from pediatric to adult health care. It encompasses much more than the transfer of care from a pediatric to an adult care setting. Health education on selfmanagement, legal and financial decision-making, choices about education and careers are all important factors that help ensure the health and productivity of young adults. Obstacles to a successful transition may include: lack of available adult providers who are comfortable caring for young adults with special health care needs; lack of provider time and reimbursement; and lack of youth/family preparation and education around transition. Although a planned transition is important for all youth, it is especially important for children and youth with special health care needs (CYSHCN). A well-planned transition may be conducive to continuity of care, medication management, and prevention of chronic conditions. Nationally, only 40% of CYSHCN receive the services they need to make successful transitions to adult health care, work, and independence, according to data from the National Survey of Children with Special Health Care Needs. In Wisconsin, just 44% of adolescents met these outcomes. Nationally and in Wisconsin, youth who are minorities, who have mental health and developmental conditions and who have disabling chronic conditions are disproportionately represented among those without adequate transition support. In July 2011, three national health professional organizations (American Academy of Pediatrics, American College of Physicians, American Academy of Family Practice) issued a clinical report on Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home. The report highlights the critical roles for health care providers in pediatrics, family medicine, med-peds, and adult care as they support adolescents in their growth towards increased independence and self-management of their own health care.

2 Grant Guidance: Youth Health Transition Quality Improvement Grant Wisconsin Children and Youth with Special Health Care Needs The federal Maternal and Child Health Bureau funds a national center to support health care systems to be responsive to the concerns of youth with special health care needs, and to guide states and local practices. The Center for Health Care Transition Improvement, Got Transition, is housed at the National Alliance to Advance Adolescent Health. This national center has developed transition tools including the Six Core Elements of Youth Health Transition which offer guidance for clinical practice. For the last decade, Wisconsin s Title V CYSHCN Program, in partnership with state and local organizations, has provided funding to improve youth health transition, including the establishment of a statewide Youth Health Transition Initiative (YHTI). The YHTI, based at the Waisman Center at UW- Madison, facilitates networking and sharing of ideas and best practices around transition via a Learning Community and the Health Transition Wisconsin website. The YHTI will administer these grants and offer technical assistance and support to grantees. The grants will utilize Got Transition s model for implementation of practice site quality improvements, including the Six Core Elements, assessment tools and other materials. YOUTH HEALTH TRANSITION QUALITY IMPROVEMENT GRANTS The Youth Health Transition Quality Improvement grants are designed to support practices and health care systems in initiating one or more quality improvement processes that will support provider, youth and family awareness and engagement, as well as increase knowledge and skills to support successful health care transition from pediatric to adult health care. Got Transition s Six Core Elements will guide grantees through strategies recommended for transition. Teams will be provided with opportunities to assess, learn, practice, support, and sustain. Grant work will aide teams in assessing their current transition status, educate and build awareness among staff using evidence-based tools and resources, implement transition quality improvement efforts, and sustain efforts after completion of the grant cycle. Teams will also share strategies and challenges with other grantees while receiving technical assistance from the YHTI staff. 2

3 Grant Guidance: Youth Health Transition Quality Improvement Grant Wisconsin Children and Youth with Special Health Care Needs REQUIRED ACTIVITIES Youth Health Transition teams will implement the required strategies to build and/or improve the current system of care for youth transitioning from pediatric to adult health care. The following is a list of required activities under Assess, Learn, Practice, and Support/Sustain. Assess 1. Identify a person to act as the transition project coordinator. This could be a member of clinical leadership, a physician, or another member of the health care team willing to oversee grant work and will have dedicated time for the project. 2. Identify team members to participate on youth health transition team. The team should include at minimum: the project coordinator; clinicians or providers (adult and/or pediatric); youth representative; and an adult family member or guardian representative. Youth and family representatives do not need to be related. 3. Identify and connect with your nearest Regional Center for CYSHCN 4. Complete Got Transition s Current Assessment of Health Care Transition Activities (submitted with application, but score will not influence funding decisions), to identify area(s) of focus for grant application submission. 5. Complete Got Transition s Health Care Transition Process Measurement Tool by January 31, 2017 (pre) and by January 31, 2018 (post). 6. Obtain written commitment of support for Transition efforts from executive leadership. Learn 1. Recruit, organize, and conduct a minimum of one medical practice educational presentation for clinicians and care team staff to advance successful health care transition concepts. All presentations will use and promote a unified definition, set of tools, and messages to be adopted, endorsed, and used by providers and staff. The presentation will be done in collaboration with professionals from your Regional Center for CYSHCN and the YHTI coordinator. Content and presentation materials will be provided by YHTI staff. 2. Participate in Learning Community calls with other grantees and health care teams in the state on successful strategies for promoting and supporting the components of youth to adult health care Transition. Learning Community calls will occur every second Wednesday of even months from 12pm to 1pm: February 7, April 12, June 14, and August 9, The Project Coordinator will be required to attend these calls. Practice 1. Identify at least ten youth of transition age (14-21 years old) and their families to participate in one event hosted by the Youth Health Transition project. The event should include sharing information and a process to assist youth and their families in assessing their own readiness for transition with support from the health care Transition team. 2. Engage in a quality improvement (QI) process to develop and improve health care workflow based on the initial team assessment and selected project area of transition focus to achieve desired outcomes that are time specific and measurable. 3. Using the reporting system provided, track and report quarterly the Transition outcomes and provide feedback collected from families and providers about these processes. Use resulting information to shape practice guidelines and educational materials for families. Support/Sustain 1. Participate in an end-of-the-year in-person meeting where Transition teams will share experiences and what teams learned, as well as to celebrate and sustain their successes. This will occur in the last or fourth quarter of the project, tentatively scheduled for Tuesday, November 14, Final project report will include plans for sustaining successful youth health transition strategies that have been implemented. 3

4 TIMELINE OF REQUIRED ACTIVITES Grant Guidance: Youth Health Transition Quality Improvement Grant Wisconsin Children and Youth with Special Health Care Needs 2016: Pre-Application Month Date Activity September - Decide to submit application November Identify team members to participate: including project coordinator; provider; youth representative; and family member representative (do not need to be related). Identify and connect with your nearest Regional Center for CYSHCN Complete Current Assessment of Health Care Transition activities to identify focus area(s), submitted with application, score will not influence funding decision Obtain written commitment of support from executive leadership Complete and submit application 2017: Grant Period Month Date Activity January January 1-31 Call with YHTI Team to be scheduled based on availability of project coordinator January 31 Complete baseline Got Transition s Health Care Transition Process Measurement. February February 8 Learning Community Call (1 of 4) February 28 Quality Improvement AIMs statement due to YHTI Coordinator April April 7 Quarter 1 data on outcomes and provider/family feedback due April 12 Learning Community Call (2 of 4) June June 14 Learning Community Call (3 of 4) July July 7 Quarter 2 data on outcomes and provider/family feedback. August August 9 Learning Community Call (4 of 4) October October 7 Quarter 3 data on outcomes and provider/family feedback November November 14 (tentative) Grantee Meeting (in-person) December December 31 Project Completion 2018: Post Grant Month Date Activity January January 31 Got Transition s Health Care Transition Process Measurement tool due Final Report Due 4

5 Grant Guidance: Youth Health Transition Quality Improvement Grant Wisconsin Children and Youth with Special Health Care Needs EXPECTED OUTCOMES The goal of the grants is to enable teams to implement one or more quality improvement strategies related to youth health transition. These strategies will be based on the strategies of Got Transition s Six Core Elements of Health Care Transition. Got Transition recommends a policy pertaining to transition and/or to young adult health care is critical. Therefore, all teams are expected to select policy as a focus area if their organization or clinic does not currently have a Health Transition policy or guideline in place. The examples below provide applicants with additional quality improvement strategies that could be implemented in pediatric and adult health care settings as part of the grant work. These are examples; applicants will identify a focus area by completing Got Transition s Current Assessment of Health Care Transition Activities, and choose one or more outcomes based on results. Teams will utilize the Plan-Do-Study-Act (PDSA) process to conduct small tests of change, as described by the Institute for Healthcare Improvement (IHI). Teams are expected to begin the PDSA process by constructing an AIM statement outlining what they hope to accomplish, with quantifiable targets and measures. Teams will continue to implement PDSA cycles throughout the grant year, and reporting on the outcomes of each cycle. The Six Core Elements are provided below for additional strategy ideas. Examples of Transition Strategies: Core Elements Pediatric care setting Family med/med peds Adult care setting Written policy Develop and implement a written transition policy Develop and implement a written policy on young adult privacy and Develop and implement a written transition policy Registry/tracking and monitoring Transition readiness Transition planning Transition and transfer of care Transition completion ELIGIBLE APPLICANTS Implement a system to track transitioning youth (EHR, etc.) Implement use of a tool to assess transition readiness Implement use of a transition planning tool (e.g., portable medical summary) Assure communication with adult primary care providers and specialists Implement processes for pediatric providers to serve as resources for adult providers post-transfer consent Implement a system to track transitioning youth Implement use of a tool to assess self-care knowledge Prepare youth/family for adult approach to care, including changes to privacy and decisionmaking at 18 Implement adult approach to care-- privacy and consent Assist young adult with accessing adult specialists Implement a system to track young adults in practice Offer transitioning youth opportunities to learn about adult care setting before initial visits Ensure receipt of transfer package from pediatric care setting (transition assessments, etc.) Implement processes to review transition information shared by pediatric practice Implement processes to communicate as needed with pediatric providers post-transfer Health care providers in clinical settings are eligible to apply. Previous grantees are eligible to apply and will be required to build off of previous grant work activities. Once a practice decides to apply, a team of key stakeholders will need to be identified for the Transition Grant Team. Grant Teams will include personnel from many of the following areas: the pediatric and adult care systems, nursing, social work, care coordination, information technology (IT), quality improvement, youth representatives, and family members. 5

6 Grant Guidance: Youth Health Transition Quality Improvement Grant Wisconsin Children and Youth with Special Health Care Needs Teams are expected to have executive (senior leadership) sponsors representing both the pediatric and adult care settings (if practice setting is family medicine or med-peds and patients won t be changing providers, only one executive sponsor is needed). A designated project coordinator must commit to spending approximately four hours per week on project-related work. Teams will be required to partner with staff from the nearest Regional Center for CYSHCN to discuss and learn about practices to support successful health care Transitions and support family and youth participation. Teams will also be required to identify at least one adolescent and one adult to participate on Transition team as well as at least ten youth of transition age (14-21 years old) and their families within the practice to participate in the Youth Health Transition pilot project. Additional resources for engaging youth and families could include Family Voices of Wisconsin and Parent 2 Parent of Wisconsin. USE OF GRANT FUNDS Grant funds can be used to pay for the site coordinator s time, supplies, resources, meetings, travel, parent/youth honoraria, or other costs associated with the project initiatives. Funds cannot be used to purchase capital equipment. OPTIONAL IN-KIND MATCH In-kind match of up to $15,000 would assist the Youth Health Transition Initiative (YHTI) in meeting the match requirements associated with these grant dollars. Grantees may report an in-kind match used to support this project for work completed by individuals participating in the project. Individuals eligible to contribute to in-kind match may not have their salary funded by these grant dollars or other federal funding. If funded, YHTI will gather more information from grantees on reported matching funds to ensure consistency with match requirements. INFORMATION ON GRANT APPLICATION PROCESS A Grant Information call is scheduled for Tuesday, October 4 from 1:45pm to 2:30pm. This call will provide background information and address questions regarding this application. Register here. Call information: , conference ID followed by #. Questions regarding the call can be ed to Maia Stitt, Youth Health Transition Initiative (YHTI) Coordinator at Maia.Stitt@wisc.edu. Registration for this call is recommended. 6

7 Grant Guidance: Youth Health Transition Quality Improvement Grant Wisconsin Children and Youth with Special Health Care Needs SELECTION PROCESS Applications will be reviewed by a committee and ranked based on the following review criteria: Criteria Focus of Quality Improvement (QI) Project Project focuses on implementing a strategy/strategies based on the Six Core Elements pertaining to youth health transition. Project must include a focus on a transition and/or young adult care policy if organization or clinic does not currently have a Health Transition policy or guideline in place. Staffing Multidisciplinary team has been identified, which includes Project Coordinator. Senior leadership support is in place. Youth and Family Involvement Strategies have been identified to involve transition-age youth and their families throughout project. Activities and Outcomes (work plan) Applicant has outlined activities that can be implemented during grant period and for which outcomes can be evaluated. Activities must include development and/or implementation of a transition and/or young adult care policy if organization or clinic does not currently have a Health Transition policy or guideline in place. Sustainability and Dissemination Applicant has outlined a plan for sustaining and spreading transition quality improvement efforts after funding has ended, and for aligning them with other practice initiatives. Points Possible Budget 10 The budget outlines a plan for spending during the grant period and meets grant criteria. Total Score 100 Applications must be received by November 4, 2016, 5:00 PM CST. Applications available for electronic submission at If you require assistance in submitting your application, please contact: Maia Stitt, MS, Youth Health Transition Initiative Coordinator Waisman Center University Center for Excellence in Developmental Disabilities (UCEDD) 1500 Highland Avenue - Room A124 Madison, WI Maia.Stitt@wisc.edu Phone:

8 Grant Guidance: Youth Health Transition Quality Improvement Grant Wisconsin Children and Youth with Special Health Care Needs APPENDIX Role Expectations Project Coordinator Spend approximately four hours a week on project Coordinate efforts across multiple practice sites (if applicable) Convene regular meetings of team members Participate in monthly calls with Youth Health Transition Initiative (YHTI) Coordinator Participate in four one-hour Transition Learning Community calls that occur during the project Submit pre and post Health Care Transition Process Management Tools and four reporting surveys to YHTI Coordinator Communicate any team questions or concerns to the YHTI Coordinator Monitor progress on work plan activities and outcomes Help sustain and spread quality improvement after the funding ends Complete final project report and submit to YHTI Coordinator Attend a one-day Fall 2017 face-to-face meeting and share results Executive Sponsor(s) (representing both pediatric and adult care settings; if practice setting is family medicine or med-peds and patient don t change providers, only one Executive Sponsor is needed) Support team efforts with organizational resources Recognize improvements within organization Facilitate opportunities for team to share project results within organization Team Members (including one adolescent of transition age and one family member) Attend team meetings Collaborate to craft and apply AIM statement Complete required action items between meetings Utilize PDSA process Sustain and share quality improvement work Attend a one-day Fall 2017 face-to-face meeting Youth Health Transition (YHT) Initiative Administer grants Connect awardees to Regional Center for CYSHCN Provide technical assistance as needed to sites in partnership with Regional Center staff Facilitate monthly technical assistance calls for project coordinators Coordinate Transition Learning Community calls Organize Fall 2017 face-to-face meeting 8

9 Current Assessment of Health Care Transition Activities for Transitioning Youth to Adult Health Care Providers Six Core Elements of Health Care Transition 2.0 Element Level 1 Level 2 Level 3 Level 4 Score 1. Transition Policy 2. Transition Tracking and Monitoring Clinicians vary in their approach to health care transition, including the appropriate age for transfer to adult providers. Clinicians vary in the identification of transitioning youth, but most wait until close to the age of transfer to identify and prepare youth. Clinicians follow a uniform but not a written policy about the age for transfer. The approach for transition planning differs among clinicians. Clinicians use patient records to document certain relevant transition information (e.g., future provider information, date of transfer). 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. 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. 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. 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. Transition Readiness 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. 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. 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. 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 Transition Planning 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. 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. 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. 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. Got Transition /Center for Health Care Transition Improvement, 01/2014 Got Transition is a program of The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB Continued»

10 Current Assessment of Health Care Transition Activities for Transitioning Youth to Adult Health Care Providers (continued) Six Core Elements of Health Care Transition 2.0 Element Level 1 Level 2 Level 3 Level 4 Score 5. Transfer of Care Clinicians usually send medical records to adult providers in response to transitioning patient requests. Clinicians consistently send medical records to adult providers for their transitioning patients. 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). 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 Youth and Family Feedback Youth and Family Leadership Clinicians have no formal process for follow-up with patients who have transferred to new adult providers. The practice has no formal process to obtain feedback from youth and families about transition support. Clinicians provide youth and families with tools and information about health care transition. Clinicians encourage patients to let them know whether or not the transfer to new adult provider went smoothly. The practice obtains feedback from youth and families using a transition survey. The practice involves youth and families in creating and implementing education programs for practice staff related to transition. The pediatric practice communicates with the adult practice confirming completion of transfer/ first appointment and offering consultation assistance, if needed. The practice involves youth and families in developing or reviewing the transition survey and conducts the survey with eligible youth and families. The practice includes youth and families as active members of a youth advisory council for transition or a transition quality improvement team. The practice confirms transfer completion, need for consultation assistance, and elicits feedback from patients regarding the transition experience. The practice involves youth and families in developing or reviewing the transition survey, conducts the survey with eligible youth and families, and involves youth and families in developing strategies to address areas of concern identified by the transition survey. The practice ensures equal representation of youth and families in strategic planning related to health care transition. The table at right can be used to total the number of points that your practice obtained on the pediatric version of the Current Assessment of Health Care Transition Activities. This form is being completed to asses: An Individual Provider An Individual Practice A Practice Network Transition Activities Score Possible Score Transition Policy 4 Tracking and Monitoring 4 Transition Readiness 4 Transition Planning 4 Transfer of Care 4 Transfer Completion 4 Youth and Family Feedback 4 Youth and Family Leadership 4 Total 32 Got Transition /Center for Health Care Transition Improvement, 01/2014 Got Transition is a program of The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB

11 Current Assessment of Health Care Transition Activities for Transitioning to an Adult Approach to Health Care Without Changing Providers Six Core Elements of Health Care Transition 2.0 Element Level 1 Level 2 Level 3 Level 4 Score 1. Transition Policy Clinicians vary in their approach to preparing youth for an adult approach to care. Clinicians follow a uniform but not a written transition policy about preparing youth for an adult approach to care. The approach for transition planning differs among clinicians. The practice has a written transition policy or approach about preparing youth for an adult approach to care, developed with input from youth and families, which includes privacy and consent information. The policy is not consistently shared with youth and families. The practice has a written transition policy or approach about preparing youth for an adult approach to care, developed with input from youth and families, which includes privacy and consent information. Clinicians discuss it with youth and families beginning at ages 12 to 14. The policy is publicly posted and familiar to all staff. 2. Transition Tracking and Monitoring 3. Transition Readiness 4. Transition Planning/ Integration into Adult Approach to Care Clinicians vary in the identification of transitioning youth, but most wait until close to the age of 18 to identify and prepare youth for an adult approach to care. Clinicians vary in terms of the age when youth begin to have time alone during preventive visits without the parent/caregiver present. Transition readiness/self-care is seldom assessed. Clinicians vary in addressing health care transition needs and goals. They seldom make available to youth/young adults a plan of care (including medical summary and emergency care plan and transition goals and action steps.) Clinicians use patient records to document certain relevant transition information (e.g., legal documents related to supported decision-making). 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 close to the age of 18. Clinicians consistently address transition needs and goals as part of the plan of care, but seldom update and share the plan with youth/young adults. 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 to prepare for an adult approach to care. 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 an adult approach to care beginning at ages 14 to 16, but no formal transition readiness/self-care assessment tool is used. The practice partners with youth/young adults in developing and updating their plan of care with prioritized transition goals. This plan of care is regularly updated and accessible to youth/young adults. 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. 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. 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 for all patients. The practice assists youth in identifying adult specialty providers, if needed. Got Transition /Center for Health Care Transition Improvement, 01/2014 Got Transition is a program of The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB Continued»

12 Current Assessment of Health Care Transition Activities for Transitioning to an Adult Approach to Health Care Without Changing Providers (continued) Six Core Elements of Health Care Transition 2.0 Element Level 1 Level 2 Level 3 Level 4 Score 5. Transfer to Adult Approach to Care Clinicians vary in discussing privacy and consent issues at age 18. Clinicians consistently discuss privacy and consent issues at age 18. Clinicians discuss privacy and consent issues at age 18 and document in medical records. All young adults ages 18 and older sign privacy and consent forms allowing others to be present at the visit, if needed. 6. Transfer Completion/ Ongoing Care Clinicians have no formal process for feedback with young adults who have transitioned to an adult approach to care Clinicians encourage some patients to let them know whether or not the transition to an adult approach to care went smoothly. The practice elicits feedback from most young adults regarding the transition to an adult approach to care. The practice uses a standardized survey to elicit feedback from young adults regarding the transition to an adult approach to care. Youth, Family, The practice has no formal process to obtain The practice obtains feedback from youth, fami- The practice involves youth, families, and young The practice involves youth, families, and young and Young Adult feedback from youth, families, and young adults lies, and young adults about the transition to an adults in developing or reviewing the transition adults in developing or reviewing the transition Feedback about the transition to an adult approach to care. adult approach to care using a transition survey. survey and conducts the survey with eligible survey, conducts the survey with eligible youth, youth and families. families, and young adults, and involves youth, families, and young adults in developing strategies to address areas of concern identified by the transition survey. Youth, Family, and Young Adult Leadership Clinicians provide youth, families, and young adults with information about transition to an adult approach to care. The practice involves youth, families, and young adults in creating and implementing education programs for practice staff related to the transition and special health needs of young adults. The practice includes youth, families, and young adults as active members of a quality improvement team. The practice ensures equal representation of youth, families, and young adults in ongoing strategic planning related to the care of young adults. The table at right can be used to total the number of points that your practice obtained on the pediatric version of the Current Assessment of Health Care Transition Activities. This form is being completed to asses: An Individual Provider An Individual Practice A Practice Network Transition Activities Score Possible Score Transition Policy 4 Tracking and Monitoring 4 Transition Readiness 4 Transition Planning/Integration into Adult Approach to Care 4 Transfer to Adult Approach to Care 4 Transfer Completion/Ongoing Care 4 Youth, Family and Young Adult Feedback 4 Youth, Family and Young Adult Leadership 4 Total 32 Got Transition /Center for Health Care Transition Improvement, 01/2014 Got Transition is a program of The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB

13 Current Assessment of Health Care Transition Activities for Integrating Young Adults into Adult Health Care Six Core Elements of Health Care Transition 2.0 Element Level 1 Level 2 Level 3 Level 4 Score 1. Young Adult Transition and Care Policy 2. Tracking and Monitoring 3. Transition Readiness/ Orientation to Adult Practice Clinicians vary in their approach to new young adult patients, and most often approach new young adults as any new patient group, requesting that they complete new patient information forms. Clinicians have no mechanism to identify new young adults in the practice and their level of selfcare skills. Clinicians have no welcome process tailored to new young adult patients, and there is no organized process within the practice to identify clinicians interested in caring for young adults. Clinicians follow a uniform, but not a written health care transition policy about the practice s approach for accepting new young adults, assisting them in gaining knowledge of the adult health care system. Clinicians use patient charts to record certain relevant transition information (e.g., medical summary, self-care assessment). Clinicians within the practice have self-selected to accept new young adult patients, and the practice makes available general introductory information for all new patients of all ages. The practice has a written health care transition and care policy or approach, developed with input from young adults, which describes the practice s approach for partnering with new young adult patients and explains privacy and consent in understandable language. The practice has an individual transition flow sheet or transition registry for identifying and tracking new young adult patients, or a subgroup of young adults with chronic conditions, as they progress through and complete some but not all transition processes. The practice has a list of providers interested in caring for young adults that it shares with new young adult patients and pediatric practices. It also makes available general introductory information for all new patients. The practice has a written health care transition and care policy or approach, developed with input from young adults, and it is publicly displayed and discussed with new young adult patients. All staff are familiar with the policy. The practice has an individual transition flow sheet or registry for identifying and tracking new young adult patients, or a subgroup of young adults with chronic conditions, as they progress through and complete all Six Core Elements of Health Care Transition, using EHR if possible. The practice has a packet of materials tailored to young adults orienting them to the practice and including a list of providers interested in caring for young adults. The practice offers get-acquainted appointments, if feasible. 4. Transition Planning/ Integration into Adult Practice Clinicians vary in whether they request previous records before seeing a new young adult patient. Clinicians receive and review previous records prior to seeing new young adult patients and determine if any special accommodations are needed. The practice ensures receipt of complete transfer package (including final readiness assessment, medical summary, emergency plan, and, if needed, legal documents, and condition fact sheet) for each transitioning young adult patient and determines if special accommodations are needed. Prior to the first visit, the care team makes a previsit call to all new young adult patients, reviews the transfer package (including final readiness assessment, medical summary, emergency plan, and, if needed, legal documents, and condition fact sheet) and communicates with the pediatric practice. Continued» Got Transition /Center for Health Care Transition Improvement, 01/2014 Got Transition is a program of The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB

14 Current Assessment of Health Care Transition Activities for Integrating Young Adults into Adult Health Care (continued) Six Core Elements of Health Care Transition 2.0 Element Level 1 Level 2 Level 3 Level 4 Score 5. Transfer of Care/Initial Visit Clinicians vary in addressing self-care needs and health priorities among new young adult patients. Clinicians discuss young adults concerns about transferring to a new adult provider, the distinctions in adult-centered care from pediatric care, and self-care needs and health priorities. Prior to the first visit, clinicians review young adult s transfer package (including final transition readiness assessment, medical summary, emergency plan, legal documents, and condition fact sheet), and during the first visit, partner with the young adult patient in reviewing self-care needs and priorities, unique aspects of adult-centered care, and concerns about changing from pediatric to adult care. The practice uses a standardized self-care assessment tool and incorporates self-care assessment into a plan of care template in its EHR. Clinicians partner with young adults in updating their plan of care, reviewing unique aspects of adult-centered care, and concerns about changing from pediatric to adult care. The young adult s plan of care is accessible to them. 6. Transfer Completion/ Ongoing Care Clinicians rarely communicate with and/or seek consultation assistance from pediatric providers after transfer. Clinicians are responsive to pediatric transfer requests, but generally do not follow-up for consultation assistance. Adult providers assist new young adult patients in identifying adult specialty providers. The practice has an organized process to ensure that adult clinicians receive consultation support or training for childhood-onset conditions. Adult providers assist new young adult patients in identifying adult specialty providers. The practice consistently works with pediatric practices to consult and co-manage care of young adults with complex conditions and assists new young adult patients in connecting with adult specialists and community resources. The practice also elicits feedback about young adults experience with care. Young Adult Feedback The practice has no formal process to obtain feedback from young adults about transition support/assistance. The practice obtains feedback from young adults using a transition feedback survey. The practice involves young adults in developing or reviewing the transition feedback survey. The practice involves young adults in developing strategies to address areas of concern identified by the transition feedback survey. Young Adult Leadership Clinicians provide young adults with tools and information about the adult approach to health care. The practice involves young adults in creating and implementing education programs for practice staff related to the care of young adults. The practice includes young adults as active members of a young adult advisory council or a quality improvement team. The practice involves young adults in strategic planning related to the care of young adults. The table at right can be used to total the number of points that your practice obtained on the adult version of the Current Assessment of Health Care Transition Activities. This form is being completed to asses: An Individual Provider An Individual Practice A Practice Network Transition Activities Score Possible Score Transition Policy 4 Tracking and Monitoring 4 Transition Readiness/Orientation to Adult Practice 4 Transition Planning/Integration into Adult Practice 4 Transfer of Care/Initial Visit 4 Transfer Completion/Ongoing Care 4 Young Adult Feedback 4 Young Adult Leadership 4 Total 32 Got Transition /Center for Health Care Transition Improvement, 01/2014 Got Transition is a program of The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB

15 2017 Youth Health Transition Quality Improvement Grant Application Introduction The Youth Health Transition (YHT) Initiative at the University of Wisconsin Madison - Waisman Center is releasing this Request for Proposals (RFP) to support implementation of health care transition quality improvement processes at Wisconsin health care practices. Based on available funds, up to five grants of up to $20,000 each will be offered. Projects will run from January 1, 2017 through December 31, 2017, including a one-day event at which grantees will share their experiences. Applications are due November 4, Award notifications will be released December 9, Prior to beginning your application, please review the Youth Health Transition Quality Improvement Grant Guidance. If your team is also applying for a Medical Home Quality Improvement grant, a separate application must be completed. 1

16 2017 Youth Health Transition Quality Improvement Grant Application Demographic Information 1. Demographic information: Contact Person: Medical Practice or Health System Name: Address: Address 2: City/Town: State: -- select state -- ZIP: County: Address: Phone Number: 2. Practice Setting: Please select the practice setting(s) in which your transition quality improvement work will occur (select all that apply). Clinic-pediatric primary care Clinic-family medicine/med peds Clinic-adult medicine primary care Clinic-pediatric specialty care Clinic-adult specialty care Other (please specify) 2

17 3. Team: Grant Teams will include personnel from many of the following areas: the pediatric and adult care systems, nursing, social work, care coordination, information technology (IT), quality improvement, and youth/family. Teams are expected to have executive (senior leadership) sponsors representing both the pediatric and adult care settings (if practice setting is family medicine or med-peds and patients won t be changing providers, only one executive sponsor is needed.) Please indicate if pediatric or adult care setting. Adult Provider (indicate setting): Pediatric Provider (indicate setting): Project Coordinator (indicate setting): Youth/family representative (indicate setting): Executive Sponsor (indicate setting)*: Executive Sponsor (indicate setting)*: Other Team Members: *Executive Sponsor (senior leadership) should represent both the pediatric and adult care settings. If a family medicine or med-peds setting, then only one Executive Sponsor is required. 4. Grantees will partner with professionals from their Regional Center for Children and Youth with Special Healthcare Needs (CYSHCN). Please select the Regional Center with which you will be partnering. If you are not familiar with the Regional Centers for CYSHCN, please refer to this map for additional information about the Regional Centers. Northern Regional Center Northeast Regional Center Southern Regional Center Southeast Regional Center Western Regional Center 3

18 5. Patient Population: Briefly describe the patient population seen by this health care facility that could be impacted by this quality improvement project. Also provide the projected sample size of patients participating in this quality improvement effort during the grant term. 4

19 2017 Youth Health Transition Quality Improvement Grant Application Project Description Elements The Six Core Elements of Health Care Transition will provide the quality improvement framework for this grant application. There are three sets of customizable tools available for different practice settings. The Current Assessment of Health Care Transition Activities measurement tool gives individual providers, practices, or networks a snapshot regarding how far along they are in implementing the Six Core Elements. Practice teams should choose the version(s) most applicable to their setting(s), and complete as part of the application process. Use the results to help refine your quality improvement focus area(s). Current Assessments: Youth to Adult Health Care Providers Adult Approach to Health Care without Changing Providers Integrating Youth Adults into Adult Health Care Please send the completed assessment as an attachment to Maia Stitt at maia.stitt@wisc.edu. Please note: While we ask for the assessment to be submitted with the application, these assessments and scores will not influence the grant review and funding decisions. 5

20 6. Focus of Quality Improvement (QI) Project: Based on your answers to the Current Assessments completed above, identify a focus area(s) for your transition efforts. In the following space, please describe and document a reasonable plan to carry out the activities listed in the work plan. Indicate the focus area(s) for the project and briefly describe how you will address this area(s). All teams must include a focus on policy if their organization or clinic does not currently have a Health Transition Policy or Guideline in place. Six Core Elements - Transition Focus Area(s): check all that apply Transition Policy Transition readiness Transition and transfer of care Monitoring/tracking Transition planning Transition completion Brief description: 6

21 7. Staffing: Describe how you will establish a multidisciplinary team with a Project Coordinator. Grant Teams will include personnel from many of the following areas: the pediatric and adult care systems, nursing, social work, care coordination, information technology (IT), quality improvement, and youth/family. Describe executive sponsors(s) role. 8. Children and Youth with Special Health Care Needs (CYSHCN) Involvement: Describe how you will involve CYSHCN and their families. 7