Post on 23-Dec-2015
transcript
Transition to Adulthood:Future Directions in Professional Education
KITTY O’HARE, MD
INTERNAL MEDICINE-PEDIATRICS
ASSISTANT PROFESSOR, HARVARD MEDICAL SCHOOL
DisclosuresI have no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Educate:Latin “educere”- to lead forthMERRIAM-WEBSTER DICTIONARY
Agenda1. Review the literature
2. Examples of educational models and curricula
3. Apply educational theory to transition
Let us pick up our books and our pens. They are our most powerful weapons.MALALA YOUSAFZAI
2002 Consensus Statement
Identified 6 priorities for improving young adult transitions, including:
“Train primary care providers in transition services”
AAP/AAFP/ACP-ASIM. A Consensus Statement on Health Care Transitions for Young Adults With Special Health Care Needs. Pediatrics 2002; 110:1304-6.
2011 Consensus Statement
Identified 6 areas for quality improvement, including:
“Promotion of training and clinical experience on transition and transfer of youth and young adults (both with and without special needs) for trainees in all medical fields.”
Transitions Clinical Report Authoring Group, Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home. Pediatrics 2011; 128:181-202.
Internists’ Perspectives on TransitionRandom survey of U.S. board-certified Internists
Asked to name and rank their concerns about transition
2 out of 5 top concerns related to training
Peter NG et al. Transition from Pediatric to Adult Care: Internists’ Perspectives. Pediatrics 2009; 123:417-23.
Item Mean Likert Rating
Category Wilcoxon Rank
Internists may not have the training in congenital and childhood chronic illness to prepare them to manage them beyond childhood.
2.86 Medical competency
1
It is difficult to care for patients with cerebral palsy or mental retardation if the family does not stay involved.
2.86 Family involvement
1
It can be difficult to meet psychosocial needs of young adults, especially those living with chronic illness
2.77 Psychosocial needs
1
Some patients may need a superspecialist to manage complex problems (eg, complex congenital heart disease).
2.77 Medical competency
1
Internists often lack training in adolescent medicine, adolescent development, and adolescent behavior.
2.63 Medical competency
1
Barriers to Care: Internists vs Pediatricians
Training as a factor limiting ability to care for young adults with childhood-onset chronic diseaseInternists: Ranked 4 out of 9Pediatricians: Ranked 6 out of 9
Omukura MJ, et al. Physician Views on Barriers to Primary Care for Young Adults With Childhood-Onset Chronic Disease. Pediatrics 2010; 125:e748-54).
Comfort with Childhood-Onset Chronic Disease
Survey of 1288 U.S. internists and pediatricians
Assessed comfort with providing primary care for patients with sickle cell disease or cystic fibrosis
Okumura MJ, et al, Comfort of General Internists and General Pediatricians in Providing Care for Young Adults with Chronic Illnesses of Childhood . J Gen Intern Med 2008; 23:1621-7.
Internists=509
Pediatricians=739
P Value
Hypertension 91% 31% <0.001
Asthma 85% 86% 0.9
Diabetes mellitus, Type 1 68% 44% <0.001
Depression 54% 29% <0.001
Chronic pain 43% 16% <0.001
Sickle cell disease 32% 35% 0.3
Complex congenital heart disease
16% 42% <0.001
Cystic fibrosis 15% 38% <0.001
Internists=515
Pediatricians
=751
P Value
Proportion treated CF in residency
78% 96% <0.001
Proportion treated SCD in residency
94% 99% <0.001
Odds Ratio for Comfort to Treat in Primary Care
Internists Pediatricians
#CF patients treated in residency
1.5 1.2
#SCD patients treated in residency
1.8 1.4
Resident Comfort with Outpatients
Patel MS and O’Hare K. Residency Training in Transition of Youth with Childhood-Onset Chronic Disease. Pediatrics 2010; 126 S3:S190-3.
Likelihood to Provide Care after Residency
Patel MS and O’Hare K. Residency Training in Transition of Youth with Childhood-Onset Chronic Disease. Pediatrics 2010; 126 S3:S190-3.
Adolescent Medicine Training in
145 Pediatric Residency Programs
Chronic Illness
Not Covered
Somewhat Covered
Well Covered
Handoffs to Adult Care
14% 17%
50%
33%
49%
37%
Fox HB, et al. Adolescent Medicine Training in Pediatric Residency Programs. Pediatrics 2010; 125:165-72.
Adolescent Medicine Training in
145 Pediatric Residency Programs
Chronic Illness
Not Covered
Somewhat Covered
Well Covered
Handoffs to Adult Care
14% 17%
50%
33%
49%
37%
Fox HB, et al. Adolescent Medicine Training in Pediatric Residency Programs. Pediatrics 2010; 125:165-72.
Pediatric Resident Education in CSHCN
Nazarian B, et al. Identifying What Pediatric Residents Are Taught About Children and Youth With Special Health Care Needs and the Medical Home . Pediatrics 2010; 126: S183-9.
Caring for CSHCN in primary care
Transition to adulthood
0 10 20 30 40 50 60 70 80 90 100
% Reported Exposure to Topic% Suggested Adding Topic to Curriculum
South Carolina: Resident Preferences for Transition Curriculum
Clinical experiences Case discussions Lectures/didactics0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Mennito S. Resident preferences for a curriculum in healthcare transitions for young adults. South Med J 2012; 105:462-6.
University of Alabama: Development of a Transition Course
Key insights:
1. Need to include the voices of patients and families
2. Use of faculty from various professions and specialties to model interdisciplinary care
3. Insight that problems specific to transition offer into contemporary health care financing
Hagood JS, et al. A course on the transition to adult care of patients with childhood-onset chronic illnesses. Acad Med 2005; 80:352-5.
He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.WILLIAM OSLER
Harvard Longwood Med-Peds Crossover Curriculum
Authors: Zadok Sacks MD, Anna Volerman MD, Niraj Sharma MD MPH
Learners: Med-Peds, Pediatrics and Internal Medicine residents
Format: Resident report conferences featuring guest faculty from the opposite discipline (e.g. adult cardiologist at pediatrics report)
Feedback from Pilot (n=70 IM residents)
QUANTITATIVE
87% had no prior training related to the transitioning of YSHCN
99% stated that hearing from pediatrics subspecialists about these topics enhanced their learning
98% felt that the CC adds to their education
QUALITATIVE
“I feel much more knowledgeable on [inflammatory bowel disease] and [cystic fibrosis] and would feel more comfortable when taking care of adult patients with those diseases.”
“I will trust a sickle cell patient to tell me what dose of pain meds works for them in a pain crisis.”
“[I will be] more sensitive to [the] transition years.”
Brigham & Women’s/Boston Children’s Hospital Transition to Adult Care Conference
Authors: Kitty O’Hare, MD and Niraj Sharma, MD MPH
Learners: Physicians, nurses, social workers, trainees
>200 on list-serv; across Massachusetts and Rhode Island
Format: Monthly interdisciplinary conference
2014-15 Themes
Transition ethics
Clinical services
Patient/Family perspectives
Research
2014-15 ThemesTransition ethics
• Young adult ward & consult service• Adult physiatry• Pain team• Spina Bifida• Neurology
Clinical services
Patient/Family perspectives
Research
2014-15 ThemesTransition ethics
• Got Transition? national youth spokesperson• Parent video project
Clinical services
Patient/Family perspectives
Research
2014-15 ThemesTransition ethics
• Health plan data• A novel developmental transition assessment tool
Clinical services
Patient/Family perspectives
Research
Boston Children’s Hospital Primary Care
Author: Kitty O’Hare, MD
Learners: Pediatrics and Med-Peds residents
Format: Continuity clinic teaching case: a 17yo with Down Syndrome
1. Transition tools
2. Sexuality
3. Guardianship/End of Life
4. Education/Vocation/Housing
5. Insurance/SSI/Financial Planning
Harvard Medical School Tutorial
Authors: Niraj Sharma, MD MPH
Learners: Medical students
Format: Small group learning
Case: a 19yo with cystic fibrosis
1. The patient
2. The parent
3. The pediatric provider
4. The adult provider
AAMC MedEdPORTAL
Author: Laurie Fishman, MD
But Tommy Likes It Here: Moving to Adult Medicine MedEdPORTAL Publications; 2012. www.mededportal.org/ publication/ 9190
Learners: Healthcare professionals, trainees
Format: Cases in small group format
MUSC Transition Elective
Author: Sarah H. Mennito, MD MSCR
Learners: Med-Peds residents
Format: Month-long ambulatory rotation
Subspecialty clinics, literature review, case review, project
Baystate
Authors: Matthew Sadoff, MD
Learners: Pediatrics, Internal Medicine, and Med-Peds residents
Medical students
Format: Clinical rotation for children with medical complexity
Approach to children with medical complexitySadof M, et al. The “HEADS AT” Training Tool for Residents: A Roadmap for Caring for Children With Medical Complexity. Clin Pediatr 2014.
University of South FloridaAuthor: Janet Hess, DrPH, MPH, CHES
Learners: Pediatric and Med-Peds residents
Format: Pilot QI initiative
Multi-level intervention1. Didactic session2. Patient transition education materials made available in
clinic3. Transition tool made available in the EHR
Children’s Mercy Hospital and ClinicsSocial Work Education
Author: Terri Hickam, LCSW, LSCSW, CCM
Learners: Social workers
Format: Guardianship training course for staff
Establishing scope of practice for social workers in a team-based approach to transition
Duke Children’s ATLAS: Adolescents Transitioning to Leadership and Success
Authors: Gary Maslow, MD MPH &
Amanda Rozycki, MSW
Learners: Pediatrics residents, medical students, college students
Format: Monthly support group for YSHCN
AnMed, South CarolinaMedical Students as Transition Coaches for YSHCN
Authors: Nathan F. Bradford, MD and Brian Mulroy, DO
Learners: 3rd Year Medical students
Format: Students assigned to coach a YSHCN as they are leaving pediatrics to enter family medicine
Got Transition?
Authors: www.gottransition.org
Learners: Physicians, practicing and in training
Format: Dr. Right/Dr. Knotright YouTube videos- examples of how transition discussions can be done well (or poorly)
Illinois Chapter of the AAPOnline CME and MOC Part IV
Authors: Illinois Chapter of the AAPhttp://illinoisaap.org/projects/medical-home/transition/
Learners: Practicing Pediatricians, Internists and Family Medicine physicians
Format: Web-based CME
FloridaHATS Training for Health Care Professionals
Authors: FloridaHATS
http://www.floridahats.org/?page_id=2206
Learners: Physicians and Allied Health Professionals
Format: 10 online modules for CME/CE
University of FloridaOnline graduate certificate in transition education
Authors: University of Florida College of Education
http://education.ufl.edu/education-healthcare-transition/certificate-program/
Learners: Allied health professional students
Format: Online fee-for-enrollment certificate program
CHIPRA Massachusetts Medical Home Collaborative
Authors: NICHQ, Boston Children’s Hospital, Massachusetts Health Quality Partners, MassHealth and the University of Massachusetts
Medical School
http://medicalhome.nichq.org/solutions/chipra-medical-home
Learners: 13 inter-disciplinary teams from primary care pediatrics
Format: In-person learning sessions and conference calls
Education is the most powerful weapon which you can use to change the world.NELSON MANDELA
2014 Match Data
NMPRA 2014 Match Data, http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf.
Categorical Internal Medicine
Family Medicine
Categorical Pediatrics
Med-Peds
0 1000 2000 3000 4000 5000 6000 7000
6524
3109
2640
374
Level of Training
Adolescent Medicine
Care Handoffs
Complex Care/Chronic Disease Management
Transition to Adulthood
UME Exposure Yes No No
GME
Peds 1 month Yes Yes No
IM Exposure Yes Yes No
Med-Peds 1 month Yes Yes No
FM Exposure Yes Yes No
MOC
Peds Yes No Yes Yes
IM Yes No No No
FM Yes No Yes No
Physician Education Training Requirements
Sharma N, O'Hare K, Antonelli RC, Sawicki GS. Acad Pediatr. 2014 Mar-Apr;14(2):120-7.
Future of Physician Education
UME• Include teaching on long-term
survival of disease, and exposure to youth & families as expert faculty
GME• Residents & fellows must learn to
care for long-term survivors and about transition processes
MOC• Practicing physicians should learn
how to implement care for these patients into their practices
Sharma N, O'Hare K, Antonelli RC, Sawicki GS. Acad Pediatr. 2014 Mar-Apr;14(2):120-7 .
Future of Physician Education
GME• Residents & fellows must learn to
care for long-term survivors and about transition processes
Sharma N, O'Hare K, Antonelli RC, Sawicki GS. Acad Pediatr. 2014 Mar-Apr;14(2):120-7 .
NAS Milestones www.acgme.orgINTERNAL MEDICINE
11. Transitions patients effectively within and across health delivery systems.
Coordinates care within and across health delivery systems to optimize patient safety, increase efficiency and ensure high quality patient outcomes
Anticipates needs of patient, caregivers and future care providers and takes appropriate steps to address those needs
Role models and teaches effective transitions of care
PEDIATRICS
PC3. Provide transfer of care that ensures seamless transitions
Adapts and applies the template without error and regardless of setting or complexity; internalizes the professional responsibility aspect of hand-off communication, as evidenced by formal and explicit sharing of the conditions of transfer (e.g., time and place) and communication of those conditions to patients, families, and other members of the health care team
Family MedicineC-1 Develops meaningful, therapeutic relationships with patients and families
Has not achieved Level 1
Level 1 Level 2 Level 3 Level 4 Level 5
Recognizes that effective relationships are important to quality care
Creates a non-judgmental, safe environment to actively engage patients and families to share information and their perspectives
Effectively builds rapport with a growing panel of continuity patients and families Respects patients’ autonomy in their health care decisions and clarifies patients’ goals to provide care consistent with their values
Connects with patients and families in a continuous manner that fosters trust, respect, and understanding, including the ability to manage conflict
Role models effective, continuous, personal relationships that optimize the well-being of the patient and family
Bloom’s taxonomy
Knowledge “the recall of specifics and universals, the recall of methods and processes, or the recall of a pattern, structure, or setting.”
Comprehension “a type of understanding or apprehension such that the individual knows what is being communicated and can make use of the material or idea being communicated without necessarily
relating it to other material or seeing its fullest implications.”Application “use of abstractions in particular and concrete situations.”
Analysis “breakdown of a communication into its constituent elements or parts such that the relative hierarchy of ideas is made clear and/or the relations between ideas expressed are made
explicit.”Synthesis “putting together of elements and parts so as to form a whole.”
Evaluation “judgments about the value of material and methods for given purposes.”
Benjamin Bloom et al. Taxonomy of Education Objectives, 1956. As quoted in the Vanderbilt University Center for Teaching. http://cft.vanderbilt.edu/guides-sub-pages/blooms-taxonomy/
Bloom’s Taxonomy for Health Care TransitionEvaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Attitudes toward successful transitions
Skills to transition
Knowledge of transition
Knowledge
Define Transition to AdulthoodDefine CYSHCNPathophysiology of childhood-onset chronic conditionsAdolescent health screening guidelines
Knowledge
Knowledge
Describe barriers to transitionDescribe the 6 core elements of transitionUnderstand how disease changes from childhood to adulthoodUnderstand principles of health and wellness
Comprehension
Skills
Develop transition policiesBuild registries and develop EHR toolsAssess patients’ readiness to transitionDevelop care plans and other communication toolsTransfer care effectively
Application
Skills
Quality improvementMeasure outcomesEvaluate programs and curricula
Analysis
AttitudesCare coordinationBehavioral health integrationPatient/family partnershipsTeam-based careInter-professional collaborationCost-effectiveness
Synthesis
AttitudesDisseminate best practicesAdvocate on the local, community, state, and federal levelEnact policies favorable to youth in transitionChange the world
Evaluation
Bloom’s Taxonomy for Health Care Transition
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Attitudes toward successful transitions
Skills to transition
Knowledge of transition
Acknowledgements
Harvard Longwood Med-Peds Residency Program
Weitzman Family BRIDGES Young Adult Program at Boston Children’s Hospital
Harvard Medical School Center for Primary Care
Health Care Transition Research Consortium
Contact information
Email frances.ohare@childrens.harvard.edu
Twitter @DrKittyMD
LinkedIn www.linkedin.com/pub/kitty-o-hare