Multidisciplinary Intervention Navigation Team (MINT) for Pediatric to Adult Healthcare Transitions

Transcription

1 Multidisciplinary Intervention Navigation Team (MINT) for Pediatric to Adult Healthcare Transitions North Texas Transitional Care Sophia Jan, MD, MSHP Feb 16,

2 GOAL To increase safety and coordination of pediatric to adult health care transfers of our most vulnerable CHOP patients through individual patient interaction and infrastructure development

3 ADULT PATIENTS AT CHOP ( 18 YEARS) CHOP has a LOT of adult patients ~25,000 adult patients ( 18 years) Utilization: 75,000+ ambulatory visits/yr 4,416 admissions/yr 19,852 hospital days/yr 3,233 ED visits/yr 12.2% of total hospital charges

4 MEDICALLY COMPLEX ADULT PATIENTS Medically Complex Adult Patients 14% (3,504 pts) had 2 specialists 11% (2,750 pts) had intellectual disability High acute care use 2,250 admissions 11,084 hospital days 1,675 ED visits adult patients hospitalized at CHOP on any given day

5 TRANSITION ACROSS DIVISIONS Surveyed CHOP Divisions and Clinical Programs (N=153) in March different Divisions/programs

6 ASSESS DECISION MAKING FOR PATIENTS WITH INTELLECTUAL & DEVELOPMENTAL DISABILITIES? Almost Always 26% Usually 26% Occasionally, Rarely, or Unknown 48% 0% 20% 40% 60% 80% 100%

7 HOW OFTEN DO YOUR PATIENTS NEED TO CHANGE INSURANCE FOR ADULT PROVIDERS? Almost Always 1% Usually 3% Occasionally 22% Rarely 9% Unknown 65% 0% 20% 40% 60% 80% 100%

8 DOES YOUR DIVISION/PRACTICE DO THE FOLLOWING? ( GOT TRANSITION 6 CORE PRINCIPLES) Transition Policy Tracking & Transition Transition Planning 47% 43% 41% 37% Transfer of Care 24% Transfer Completion 13% None of the Above 7% 0% 20% 40% 60% 80% 100%

9 DOES YOUR PRACTICE DO THE FOLLOWING? CHOP Provides Medical Summary CHOP Provides Medical Records Patient Provides Medical Records 37% 35% 43% CHOP Provides Plan of Care CHOP Provides Disease Specific References 22% 19% CHOP Attends 1st Visit Non-CHOP Provider Attends CHOP Visit 7% 12% 0% 20% 40% 60% 80% 100%

10 WHAT ARE THE TOP 3 BARRIERS TO TRANSITIONING PATIENTS? Agreement Among Providers ACROSS SPECIALTIES/SERVICES on When or How to Transfer 55% Agreement Among Providers ACROSS SPECIALTIES/SERVICES on Whether to Transfer 41% Agreement Among Providers WITHIN A DIVISION on When to Transfer 37% 0% 20% 40% 60% 80% 100%

11 BIGGEST BARRIER TO TRANSITIONING PATIENTS Difficult if we are suggesting transfer but other programs (ENT) are not - often just due to parent pressure, not clinical need. It is hard to discuss transitioning [muscular dystrophy patient s] cardiac care to an adult provider if they will continue to be followed by a pediatric neuromuscular specialist here at CHOP.

12 OTHER TRANSITION BARRIERS Identifying Adult Providers Insurance Other Assessing Decision Making Information Transfer Developing Medical Summaries Assessing Transition Readiness 33% 20% 14% 12% 12% 11% 10% 0% 20% 40% 60% 80% 100%

13 IS EPIC UPDATED ONCE CARE IS TRANSFERRED? No 65% Yes 35% 0% 20% 40% 60% 80% 100%

14 IF YOU DO UPDATE EPIC, WHERE DO YOU DO IT? Notes: Progress or Consult Note Letters: Progress or Consult Note Snapshot: Specialty Commetns Snapshot: Family Comments Other Problem List Care Team 20% 10% 10% 5% 5% 1% 0% 0% 20% 40% 60% 80% 100%

15 THE ADULT PROVIDER PERSPECTIVE

16 CHOP TRANSITION PROCESSES ACROSS DIVISIONS Surveyed PennMedicine Providers (N=104) in January 2016

17 IDENTIFIED PERCEIVED BARRIERS TO TRANSITION AMONG ADULT PROVIDERS Inadequate Staffing Structure 28% Amount of Care Coordination Needed 60% Insufficient Time for Appointments 35% Insufficient Medical Knowledge/Experience 17% No Barriers 9%

18 ADULT PROVIDERS WANT MORE INFORMATION ON: Legal issues 47% Technology management 39% Community resources 79% Care coordination and enhanced reimbursement 52% End-of-life at early age 30% Teen Development / Behavior 28%

19 WHICH OF THE FOLLOWING DO ADULT PROVIDERS CONSIDER ABSOLUTELY NECESSARY? Updated medical summary Medical records prior to the first visit Access to ped EMR Verbal doc-to-doc handoff Peds visit after 1st adult visit Former Peds MD remains accessible 0% 20% 40% 60% 80% 100% Absolutely Necessary Helpful But Not Necessary Not Helpful

20 HOW OFTEN DO ADULT DOCS SEE ABSOLUTELY NECESSARY ITEMS PERFORMED? Never 10% Some of the time 48% Always / Most of the time 27%

21 WHAT WE NEEDED TO DO: Standardize transfer of care administrative processes Standardize documentation Consistent EPIC location Continue to expand and maintain adult provider network Develop clinical practice guidelines

22 EPIC CLINICAL DECISION SUPPORTS Best Practice Alert (BPA)

23 EPIC SMARTSET If accepted, BPA will open the Transition of Care SmartSet Add transition educational materials to after visit summaries Link to medical records release Link to TRAQ in Patient Flowsheets Consult to social work Consult to MINT if eligible

24 EPIC SMARTSET

25 EPIC SMARTSET

26 EPIC SMARTSET Transition of Care Problem List

27 EPIC SMARTSET Transition of Care Letter

28 MINT CONSULT SERVICE New Consult Service Eligibility 2 or more specialists AND/OR Intellectual/developmental disability Team Program Coordinator (0.2 FTE) Medical Director (0.15 FTE) Unfunded MP MD (0.2 FTE) Nurse Practitioner (0.2 FTE) Social Worker (0.2 FTE) Youth Community Health Worker (0.4 FTE) Work Study Nurse Scheduler (0.2 FTE)

29 MINT CONSULT SERVICE Team Chart Review Team Communication Intake Plan of Care Care Transfer Follow-up Review: ambulatory appointments, admissions, ED visits over past 24 months Note: Insurance, DME needs, medications, and psychosocial needs Document current care teams (MD, NPs, social work) Contact: patient's care team about transfer to adult care in 6-12 months Discuss with care team members about timing of transfer and plan of care Medical: In-depth intake with MD/NP and patient and family Psychosocial: In depth intake with SW and patient and family Determine if patient/family should be referred to our Youth Community Health Worker (YCHW) for self-care and self-management skills development Developed by synthesizing information gathered from chart abstraction, communication with care team, and intake Determine appropriate adult providers Vet transfer plan by current CHOP care team Review care plan with patient/family Assist patients/families in registering with Penn Medicine and scheduling appointments Assist patients in changing health insurance plans and coordinating nursing, home health, and DME needs if necessary for their care Communicate with pediatric and adult providers, patients/families throughout Chart abstraction to confirm that patients/families have successfully attended appointments with adult providers

30 MINT CONSULT SERVICE Table 1. Patient Demographics Age, mean (range) 21 (17-43) Number of specialists, median (range) 3 (Range: 1-8) Number of patients with IDD, n (%) 42 (70%) Table 2. Consult Activities Insurance problem, n (%) 9 (15%) Self-Advocacy/Self-Care Needs, n (%) 16 (26%) Guardianship assistance, n (%) 9 (15%) Transition Summary Started/Completed, n (%) 15 (24%) Table 3. Referred Patient Utilization Activity (since 10/2015) # of Patients Outpatient Visits ED Visits Hospital Days Consults received Consults In-Progress Consults Complete Successfully Transferred*

31 MINT CONSULT SERVICE From CHOP GI Provider [MINT has] provided us with tools to promote patient and family education, templates for our division s transition guidelines as well as editing support from both a clinical and social work perspective, technological support in the form of a Best Practice Alert [ ], and consultation support for our more medically complex patients. We would hope to be able to continue to rely on them as a partner in our transition efforts.

32 DEVELOP DIVISION INFRASTRUCTURE Began with 7 partner divisions GI, Gen Peds, Orthopedics, Neurology, Urology, Hematology, Developmental Behavior Pediatrics Partnered Divisions Committed To: 1. Identify a Division Champion 2. Transition EPIC Clinical Decision Support 3. Develop Transition Policy 4. Run a Transition Psychosocial Event Partnered Divisions Given Priority for MINT Consults Develop adult provider network

33 DEVELOP DIVISION INFRASTRUCTURE Division Activities Identify Division Champions Roll out Transition Best Practice Alert Develop Transition Policy Run Transition Psychoeducation Event 11 Identified 7 Divisions live 4 Divisions in testing 4 Divisions drafted 7 events held

34 EDUCATION MOC credit available for faculty working on transition QI project for all 3rd year Med-Peds residents

35 EDUCATION Engagement of students and trainees: nursing, MPH, PhD, undergrads, LEND fellows, Peds & Med-Peds residents, Adolescent Medicine fellow Open Transition to Adulthood LEND sessions Social Work CEUs January 2017

36 RESEARCH Poster or oral presentations HCTRC, APHA, AUCD, PAS I-ACT for Epilepsy HRSA Transition grant Proposals submitted PCORI for SCD Transitions R01 for improving QoL for AYA with CP (Penn collaboration)

37 Next STEPS Sustainability of Consult Service Integration with other complex care and care management initiatives? Capacity Management Development Expansion of Consult Service into other Hospital Systems Development of Population Health Management Tools (EPIC Healthy Planet)

38 QUESTIONS AND COMMENTS? POLICYLAB Children s Hospital of Philadelphia 3535 Market Street, 15 th Floor Philadelphia, PA jans@ .chop.edu