Health Care Transition Training for Health Care Professionals

Transcription

1 Health Care Transition Training for Health Care Professionals

2 Presenters 2 Janet Hess, DrPH University of South Florida Assistant Professor FloridaHATS Project Director (813) jhess@health.usf.edu Kelli Stannard, RN, BSN Florida Department of Health Director of Children s Medical Services Plan Clinical Operations and Specialty Programs (850) Kelli.Stannard@flhealth.gov The presenters have no conflicts or interest or financial agreements relevant to this activity to disclose.

3 Agenda 3 Development & Design Content Evaluation Dissemination

4 Development & Design 4

5 Development First training program developed by John Reiss, PhD, early researcher in health care transition from Univ. of FL In 2014, hired IL educational consultant, Jodie Bargeron, to guide reformatting and updating Continued to update annually Applied adult learning best practices Brief, targeted to learning objectives Familiar format Embedded interactivity videos, questions Natural breaks, chunks Active voice Repetition Avoid density, multiple media on single slide 5

6 Development Integrated current evidence-based research and materials 2011 Clinical Report Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home Got Transition s Six Core Elements 2.0 Coding and Reimbursement Tip Sheet Condition-specific tools for subspecialists from American College of Physicians Resources from FloridaHATS and other local/state/national programs Targeted to broad spectrum of health care practitioners Compliments physician MOC Part IV training and other educational programs available nationally 6

7 Design Narrated PowerPoint with embedded video Course split into short learning modules 10 modules, minutes each Full course length is hours Course Toolkit provides web-based resources and tools for each module 7

8 Module Design I. Learning objectives II. Significance III. Evidence base IV. Barriers V. In practice 8 VI. Using strategies and tools VII. Discuss with patients and caregivers IIX. Key points IX. Resources X. References/citations

9 Program is available to anyone at no cost FloridaHATS web site Links to modules on YouTube Downloadable copy of PowerPoint slides Florida AHEC Network Design Up to 4 free CMEs/CEs for Florida practitioners CE for physicians, PAs, nurses, social workers, mental health counselors, and other allied health professionals Structured in 2 parts (2 CEs for each part); 10-item post-test Out-of-state participants can submit certificate of completion to their accrediting agency 9

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11 Content 11

12 Course Modules Part 1: 1. Introduction 2. Adolescent Development 3. Working with Caregivers 4. Assessing Transition Readiness 5. Patient Skill Development Part 2: 6. Financial/Legal Considerations 7. Insurance 8. Working with Adult Medicine 9. Care Transfer 10. Conclusion

13 1. Introduction Defines health care transition Explains the importance of health care transition for patients Describes the current state of health care transition Provides an overview of all 10 modules 13

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15 10/15/14 5a Incorporate transition planning in chronic care management. Coordinate with CMS Nurse if patient is enrolled in CMS. Health Care Transition Preparation for Youth and Young Adults with Special Health Care Needs in Florida Is patient years? No Is patient years? No Is patient years? Age Ranges Yes Yes Yes Step1 Step 2 Step 3 Provide age-appropriate counseling and transition materials to youth and family. Identify APD eligibility and education needs. See local Helpline for other social services. Ensure Step 1. Assess transition readiness ( TRAQ or other tool). Explore post-high school options; identify decision-making needs. Establish timeline for transfer to adult primary and subspecialty care. Ensure Steps 1 and 2. Identify insurance coverage, adult service and employment needs. Transfer to adult primary and subspecialty care. Action Steps for Specific Age Ranges Is patient eligible for MedWaiver program? No Does patient have IEP? No Is patient eligible for VR? No Needs help with decisionmaking? No Insurance patient will have as adult? Determination of Services Needed Yes Yes Yes Yes See handout on Medicaid Waiver programs. For patients with I/DD, APD does intake; send all patient documents to APD. Patient is put on waiting list for APD s ibudget (home and community-based waiver). Patient may come off waiting list if urgent or emergent. Glossary: Help identify healthrelated activities to support patient s education plan. Contact Project 10 regional rep for assistance with transition IEP, starting at 14 years. Refer to Project 10 Resource Directory for local services/ programs. APD: Agency for Persons with Disabilities CMS: Children s Medical Services, Department of Health I/DD: Individuals with intellectual or developmental disabilities IEP: Individual Educational Plan TRAQ-5.0 Transition Readiness Questionnaire 5.0 (or use other checklists) VR: Vocational Rehabilitation Program Starting at age 15, send referral with patient information. VR sends information to correct geographic area for placement with VR counselor. Patient must be looking for work to receive services. Patient may be put on waiting list (handout) *Handouts are available in English, Spanish and Haitian Creole at Assist with age of majority issues before patient s 18 th birthday (advance directive, levels of guardianship, voting, other legal needs ). Refer youth/family to Florida Legal Services for legal aid. Refer patient to local Center for Independent Living for additional guidance. (handout) Discuss SSI/private and public insurance options with youth/family. Provide 411 Insurance Guide (or handout) and local contact information. Help find providers for patients; see Young Adult Health Services Directory. Call physician offices to see whether they will accept patient. 5b Have age appropriate transition issues been addressed? Care Coordination Support Yes No 5c Initiate followup interaction. 6 Transition component of interaction complete.

16 Six Core Elements 16 Transitioning Youth to Adult Health Care Providers (Pediatric, Family Medicine, and Med-Peds Providers) Transitioning to an Adult Approach to Health Care Without Changing Providers (Family Medicine and Med-Peds Providers) Integrating Young Adults into Adult Health Care (Internal Medicine, Family Medicine, Med-Peds Providers) 1. Transition Policy 1. Transition Policy 1. Young Adult Transition and Care Policy 2. Transition Tracking and Monitoring 2. Transition Tracking and Monitoring 2. Young Adult Tracking and Monitoring 3. Transition Readiness 3. Transition Readiness. 4. Transition Planning 4. Transition Planning/Integration into Adult Approach to Care 3. Transition Readiness/Orientation to Adult Practice 4. Transition Planning/Integration into Adult Practice 5. Transfer of Care 5. Transfer to Adult Approach to Care 5. Transfer of Care/Initial Visit 6. Transfer Completion 6. Transfer Completion/Ongoing Care 6. Transfer Completion/Ongoing Care

17 2. Adolescent Development Describes adolescent development stages Defines health care transition stages Provides information from the third edition of the AAP's Bright Futures and evidence-based models of care management 17

18 Transition Stages: Patient Perspective 18

19 3. Working with Caregivers Identifies key strategies and concepts for working with parents and caregivers during transition Describes frameworks for working with families during health care transition 19

20 Shared Management Model 20

21 4. Assessing Transition Readiness Discusses the importance of transition readiness assessment Shows how to administer assessment tools Demonstrates how to use assessment worksheets with patients and caregivers 21

22 Readiness Assessment Tools 22

23 5. Patient Skill Development Demonstrates how to use assessment results (shown in Module 4) to create a transition plan Lists specific steps for making a transition plan with patients Discusses tools and resources with patients and parents/caregivers Identifies activities and tasks for patients transition plans Identifies strategies to incorporate self-management and other health care transition objectives in student transition IEPs 23

24 Plan of Care 24

25 Medical Summery/Emergency Care Plan 25

26 Self-Management Guides 26

27 6. Financial/Legal Considerations Identifies legal and financial considerations during transition, including guardianship, vocational rehabilitation, and public benefits programs in adulthood Lists legal rights and responsibilities conferred at age 18 Describes programs that address legal and financial needs 27

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29 7. Insurance 29 Presents information and tools for patients to maintain continuous health insurance coverage during transition Describes common options for health insurance coverage for transition age patients Illustrates how to add insurance-related activities to transition plans

30 30 Plan for change in insurance coverage Medicaid Parents plan Employer-based Marketplace plans

31 8. Working with Adult Medicine Describes the importance of educating colleagues in adult medicine about health care transition Focuses on approaching adult practices, hospitals, and tertiary care that will serve patients after they transition out of pediatric care Lists ways to engage adult-oriented providers in the transition process Provides strategies to build a referral base of providers for the care transfer 31

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33 9. Care Transfer Examines strategies for transferring patients care to adult-oriented providers Describes characteristics of the adult health care system Illustrates how to create a practice transition policy Identifies care transfer activities for the transition plan Describes how to transfer care in a supportive manner 33

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35 10. Conclusion Reviews key points, tools, and resources from the previous modules Discusses next steps to address health care transition in practice 35

36 Practice-Based Strategies 36 Write practice transition policy Use TRAQ with patients Provide Transition Planning Guide Create annual transition plans Address legal, financial, and insurance needs Transfer care between ages 18 and 22 Engage adult medicine Interactive questions: What strategies are ready to implement? Which would be easiest? Which need time or resources?

37 Evaluation 37

38 Evaluation Methods Data reported for participants who received CE for Parts 1 and/or Part 2 through Florida AHEC (only) July 2014 December 2017 Demographics Profession Employer Location Satisfaction 11-item questionnaire Assess program content, relevancy to practice, likelihood to utilize information, overall satisfaction 38

39 Evaluation Results 126 participants for Part participants for Part 2 Demographics Profession 39 Composition Registered Nurse 70% Graduate Student 9% Social Worker 3% Physician 1% Other (includes counselor, educator) 17% Employer Florida Department of Health 54% Florida University System 8% Other (practices, hospitals, health departments, NA) 38% Location Florida 88%

40 Evaluation Results Satisfaction 40 Item Mean Score (1 low-5 high) Appropriate for the intended audience 4.50 Teaching methods were appropriate for the subject matter 4.45 Information presented could be applied to own practice 4.60 Information helpful in achieving personal professional goals 4.54 Speaker/presenter knowledge in content area 4.61 Content consistent with objectives 4.60 Speaker/presenter communicated effectively and was well prepared 4.55 How would you rate this program overall? 4.41 Was the presentation free of commercial bias? Will the information presented in this activity help you do a better job of treating patients? Will information presented during this activity lead you to make change(s) in your current practice? 92% Yes 97% Yes 79% Yes 19% Not sure or N/A

41 Dissemination 41

42 Dissemination In 2014, promotional flyer was distributed regionally, statewide and nationally through newsletters, listservs FloridaHATS regional coalitions Florida AAP chapters Florida nursing schools and associations Selected social worker networks Regional pediatric practice networks Florida Pediatric Hospital Association Health Care Transition Research Consortium Got Transition In 2016, course became required orientation for CMS Nurse Care Coordinators 42

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44 Going Forward Integrate new videos in 2018 course update Strengthen program promotion among physicians, including the CMS Plan s provider network Newly hired Title V social worker and nurse consultants (8 regions, 2 consultants per region) to work directly with practices Information provided via provider newsletters and posted on new Florida Title V website Consult with Got Transition to identify gaps and opportunities Broadly redistribute flyer to physicians, nurses, and social workers, including graduate schools 44