Improving Transitions from Child to Adult Care

Transcription

1 Improving Transitions from Child to Adult Care October 19,

2 Please introduce yourself and your organization name 4

3 Let s Tweet Together: Join the conversation #ImproveTransitions What s your twitter handle? Let us know through the chat feature so we can follow you! Please Follow 5

4 Welcome With us today: Host Jennifer Major Senior Improvement Lead CFHI Chantal Krantz Manager, Connected Care Children s Hospital of Eastern Ontario (CHEO) Ottawa Deborah Thul Social Worker Well on Your Way Youth in Transition Coordinator Alberta Children s Hospital, Calgary Khush Amaria Co-Chair, Community of Practice, Canadian Association for Paediatric Health Centres Clinical & Health Psychologist Hospital for Sick Children Toronto 6

5 Before we begin What do you want to know about improving transitions from Pediatric to Adult Health Care? Use the Chat Feature to let us know & we will be sure to try to address all questions during the webinar 7

6 On today s webinar Participants will hear about and discuss: Recommendations for improving transitions from pediatric to adult care services from the Canadian Association for Pediatric Health Centres (CAPHC) Resources and tools that can be used to inform or support improvements to transitions from pediatric to adult services How healthcare providers are working to improve transition from pediatric to adult services through the implementation of collaborative processes, tools, and resources Please ask questions and share ways you have supported improvements to transitions in your organizations using the chat feature! 8

7 Transition Vocabulary Transition: A purposeful, planned movement of adolescents with chronic medical conditions from child-centered to adult-oriented health care (Blum, 2002) that is supported by individualized planning in the paediatric & community settings, a coordinated transfer of care and secure attachment to adult services. Transfer: A one-time event that occurs when a youth is transferred out of the child health system and into the adult care system. Community of Practice (CoP): An informal learning organization that share concerns, problems and a passion about a specific issue. 9

8 What is CAPHC s Transition CoP? 10

9 Goals for CAPHC s Transition CoP National approach to developing a Guideline to: Influence transitioning at the person and clinical level, prompting change over time to the system level Ensure that all youth and their families have access to a supportive process for transitioning from paediatric to adult health services Ensure that healthcare providers have the tools and training necessary to support families and youth in this transition process 11

10 A Guideline for Transition from Paediatric to Adult Care for Youth with Special Health Care Needs (YSHCN): A National Approach Target Population Youth (aged 12 to 25 years) with special health care needs including physical, developmental and/or mental health conditions, and their families, requiring ongoing health surveillance and care to maintain optimal health into their adult years. Target Users All professional groups, allied health providers, families and caregivers who are involved in the care and transitioning of YSHCN. 12

11 A Guideline for Transition from Paediatric to Adult Health Care Includes: 19 evidence and consensus-based recommendations for the personal, clinical and system levels A growing repository of tools and resources to support organizations and clinicians in the implementation of the recommendations Examples of frameworks and models for implementation and evaluation 13

12 A Guideline for Transition from Paediatric to Adult Health Care A Quick Guide to the Recommendations, includes the level of evidence to support the practice. All of the evidence reviewed, process of development, and references (graded by level of evidence) are also included. For example: Recommendation #7 Clinical Level A developmentally appropriate individualized transition plan is prepared & documented in collaboration with youth & family. Level II - Evidence obtained from research, metaanalysis, systematic review, policy statement 14

13 Links to Transition Community, Resources and Tools KEN: Knowledge Exchange Network Choose: Communities and Networks Choose: Transition Transitions Tools & Inventory Policy Statements/guidelines Models of transitions clinics & programs Transition planning tools for care providers Timelines for transitions Readiness tools & workshops for youth, young adults, parents & caregivers Transfer documentation & processes Personal & portable health summaries Training for health professionals A series of video presentations that can improve transitions: 15

14 What Services and Programs Exist in Canada that are Improving Transitions for Youth and Young Adults with Special Health Care Needs? Here are some examples. Tell us about your services and programs to improve transitions through the chat feature! 16

15 What Services and Programs Exist in Canada that are Improving Transitions for Youth and Young Adults with Special Health Care Needs? 17

16 Transition programs in AHS Calgary Zone Example #1 South Health Campus (SHC) Adolescent Transition-In Program Supports transfer to an Adult Acute Care Site & ED 18

17 SHC Adolescent Transition-In Program Purpose: Communicate patient s specialized care needs Increase confidence in patients & families Build capacity of adult healthcare providers Pre-transfer meeting Reflects recommendation #5 and #11 in CAPHC s Guideline. Review for more information on applying in your organization. 19

18 SHC Adolescent Transition-In Visit can include: Hospital tour ICU tour Inpatient unit & room Meetings with: Patient & Family Support Specialist ICU Manager Social Work Spiritual Care Emergency Department Manager & Physician Share key patient information & care expectations Create patient record in electronic clinical management system 20

19 South Health Campus Adolescent Transition-In Program Evaluation & Feedback: 1. Focus Groups SHC Citizen Advisory Team (CAT) AB Children s Hospital Child & Youth Advisory Council (CAYAC) 2. Surveys from Patients/families Health care providers 21

20 Example #2 Successful Transitions Committee Multi-ministry committee Management representatives Addresses complex care needs of those in Calgary zone Reflects recommendation 11 & 19 in the CAPHC guidelines look there for more information on how you can do this in your organizations 22

21 Successful Transitions Committee Evaluation & Feedback: 1. Successful Transitions: Progress Report Spring 2010 Follow up surveys: 83% found consultation helpful Only a small percentage encountered difficulty in accessing services 2. Increased collaboration and cross organizational understanding Additional opportunities for shared planning & problem solving Resulting in fewer referrals for consultation 23

22 Example #3 Connecting youth & families with family physicians early via Primary Care Networks Goals: Connect patients with primary care physicians 1-2 years prior to transfer Less abrupt transfer for patients & families Build capacity of family physicians Communication & collaboration Uninterrupted & coordinated care Reflects recommendation 6 in the CAPHC guidelines look there for more information on how you can do this in your organizations

23 Connecting youth & families with family physicians early via Primary Care Networks Evaluation & Feedback 1. In process 2. Key indicators of success: a) Number of youth attached to family physicians b) Positive patient experience survey/interview c) Positive provider experience survey/interview For more information about any of these programs, contact 25

24 What Services and Programs Exist in Canada that are Improving Transitions for Youth and Young Adults with Special Health Care Needs? 26

25 Key Principles of CHEO s Corporate Transition Program Start early; foster the attainment of appropriate developmental milestones Involve child/youth and family in transition planning Use a planned and coordinated approach Ensure progressive movement towards active participation in health management Transition requires co-ordination, collaboration and communication amongst youth, families, health care providers, and health care and community-based services Reframe leaving paediatrics as an achievement One size does not fit all Continually evaluate programs/services 27

26 Identified Population Children with Special Healthcare Needs = 12-18% of kids/80% of Child Health Costs Children who are Medically Complex and Technology-dependent <1% of kids/32% of Child Health Costs All Children Cohen E, et al, Patterns and Cost of health care use of children with medical complexity. Pediatrics 2012:130(6) 28

27 Team Needs Assessment and Families Satisfaction Pre-Implementation No formal program, tools or evaluation Transition planning-rn lead Starting process at age 17 (transfer) Community organizations were not understood and underutilized. Challenge getting Specialists to consult adult counterpart early Family Feedback (from families that have already transitioned): Need to prepare earlier Need transparency and access to necessary resources Extremely stressful time 29

28 Complex Special Needs Transition Tool Kit Special Needs Youth and Parent Readiness Checklists Transition Timelines chart (birth to 18 years) Special Needs Transition Resource Guide 3 Sentence Summary (Parents/Youth) Single Point of Care Document (SPOC)-MHP Guide for clinicians (defining Roles and Responsibility) Program evaluation pre-post Transition Letter & Policy Celebrating Transition Reflects recommendation #7 and #14 in CAPHC s Guideline. Review for more information on applying in your organization. 30

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31 Steps to Success Early Introduction and transparency: Tool Kit Transition Planning Meetings yearly starting at 14yrs with Community Partners Imbedding new tools in clinic workflow: tailor to each youths capacity Documenting progress in EMR Early connection to a PCP-14years SPOC-comprehensive Medical Summary Adult Provider: support from CHEO specialist-1 year post Teens can access EPIC My Chart: 1 year after discharge Reflects recommendation #15 in CAPHC s Guideline. Review for more information on applying in your organization. 33

32 Questions? Tweet about what you ve learned & share your Please submit your questions/comments electronically using the Chat Box on the bottom of your webinar screen. 34

33 Your Next Steps Review the guideline document and Join the Transitions Community of Practice! Lisa Stromquist Contribute your tools, program information & resources to CAPCH s online Transitions Tools & Inventory Consider what you can do in the short-, medium- and long-term to improve transitions in your organization Ex. Short-term strategy: Develop your own Transition Taskforce Ex. Long-term strategy: Evaluate your organizations current transition processes Continue to raise awareness by asking questions and sharing your stories #ImproveTransitions 35

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35 Upcoming On Call webinars October 27 th - Shifting Care from Hospital to Home: Part 1 November 7 th - Catalyzing Improvement and Innovation in Canadian Healthcare November 15th - Are you ready for a little bit EXTRA? Full Lineup: 37

36 Thank