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