The following are materials for the MPPDA Workshop “Implementing Transitional Care in Your Practice Setting” PowerPoint Presentation

Many institutions look to Med-Peds program directors and programs for leadership in transitional care, yet often Med-Peds programs do not have direct clinical or administrative experience in effective health care transition.  Often times “transitional care” is equated to medical care of the highly complex young adult, when in reality transition is the process of effectively preparing, educating, and transitioning all young adults from a pediatric to an adult model of care.  In this workshop, we seek to provide Med-Peds program directors with the basic knowledge, understanding and experience necessary to begin to implement the 6 core elements of health care transition into their own practice settings, using a quality improvement framework.   First we will ask participants to perform a brief online current assessment of their practice area.  We will then review and explain the specific online tools available to implement the 6 core elements of transition available at gottransition.org, followed by breaking into smaller groups to discuss and draft an initial transition policy statement for their clinical area as well as to outline an initial PDSA cycle to start to implement this policy.  At the end of the workshop participants will be provided with several examples of how the 6 core elements are being implemented at our three institutions, which will hopefully serve as a guide for those interested in creating QI or MOC projects around effective transition. We also plan to have participants identify a colleague from within the workshop with whom to pair and check in throughout the year on progress made in this area at their home institution.

After this presentation, the audience will be able to:

1. Conceptualize what a transition process should look like according to the AAP, AAFP, and ACP clinical report

2.  List the issues needed in a transition policy statement

3.  Understand and plan 1 PDSA cycle for implementation of transition practices into your practice setting

4.  Implement a transition policy statement into your practice setting over the next 6 months (using the buddy system)

Workshop Activities:

Become Familiar with the website:  GotTransition.org and the Six Core Elements of Healthcare Transition.   The link for Providers give an excellent overview:  Got Transition For Providers

Rate your own practice site using a “Current Assessment Tool”  Please click on the following survey link to rate your current practice setting:  Current Practice Assessment Tool (survey monkey)

You may also review an online PDF of the Current Assessment from Gottransition.org: Current Assessment of Health Care Transition Activities PDF

As you begin to draft an initial transition policy, this example may serve as a starting point:

Got Transition Policy Template

Sample Transition Policy

As you get further along into your projects, here are some additional resources that might serve as useful examples:

Greenville Health System Asthma Clinic Transition Project Materials

Overall Project Timeline

Project Narrative

Transition Policy

Patient Letter

Roadmap for Transition

Roadmap for Imminent Transfer

Greenville Health System EPIC Screenshot for Transition Assessment:

 

Boston Children’s Hospital Transitional Care Materials

Boston Children’s Longwood Transitional Care Policy

Boston Children’s Teen Advisory Committee Transition Booklet

Martha Elliot Health Center Adult Patient Transition Care Packet

Martha Elliot Health Center Transition Process Map

PDSA Worksheet for Testing Change

University of Rochester Materials:

U of R EPIC Adult Transition Flowsheet

 

Transitional Care Maintenance of Certification Opportunities:

1. Illinois Chapter of the AAP

http://illinoisaap.org/projects/medical-home/transition/

–Cost: $300

2. UC San Diego/Rady Children’s Hospital

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

–Email KRose@naspghan.org for current status

3. American Academy of Pediatrics

–AAP sometimes offers Part 4 MOC credit for QI projects presented at national meetings

–Check the AAP MOC website for current information