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Transitioning from Children’s to Adult Hospital Inpatient Settings
Sarah Ahrens, MDRyan Coller, MD, MPHJody Belling, RN, MS
Context
Children’s Hospital Adult
Hospital
Chronic Conditions
and Need for Hospital Care
Growing up!Hospital
change at some point
• Errors / discontinuity• Failures in communication• Different routines and rules• Loss of familiarity• Negative experiences for Patients,
Families, Providers and Staff
Inpatient Transition Opportunities: AFCH 2007-2012
• 706 inpatient encounters for young adults ages 18-21 years– Almost 3 per week!– 57% had more > 3 “chronic conditions”
• 1860 for teenagers ages 16-17– Over 7 per week!– 37% had > 3 “chronic conditions”
Project History
Grant Opportunity
MD and NP task force from Internal Medicine,
Pediatrics, and Emergency Medicine
Late 2013
Project Goals
• Understand our current inpatient transition experience
• Create a vision for an idealized transition from hospital care in the Children’s Hospital to hospital care in the Adult Hospital
Project Description
1. Develop Transition Standards (Policy)– Based on our vision for an idealized experience
2. Develop and Pilot a Transition Planning Bundle– Again, based on our ideal
Target = Patients on Pediatric Hospitalist Service with 3 or more chronic conditions expected to be
hospitalized early in adulthood on the Internal Medicine Hospitalist Service
Core element=Policy
Core element=Transition Planning
AIM Statement
1. Define an ideal state for inpatient transitions - informing a policy for transitioning patients between hospitalist services
2. Develop and pilot test “transition planning” with 5 patients cared for by the pediatric or adult hospitalist services by Dec 31, 2014
• Additional Aims:– Identify measurable aspects of transition policy and
measurement strategy
Team Formation,
Charter
Current Process Ideal Process Pilot
Intervention
Project Approach
Planning Trials
Intervention Trials
Data Collection
Modifications, Spread
PDSA CYCLES
Team FormationRoleNursing (Pediatrics and IM) Project Coordinator
Case Management (Pediatrics and IM) Pediatric and IM Hospitalist MD
Social Work (Pediatrics and IM) Emergency Medicine MD
Child Life (Pediatrics) General Outpatient Pediatrician
Residents (Pediatrics and IM) Complex Care Program MD
Outcomes Manager (IM) EHR (Chief Med Informatics Officer)
Nurse Manager (Pediatrics and IM)
Parent Representative
Youth Representative
Current StateFrustration Themes• Lack of Process• Relationships/Conversations• Provider Disagreement• Provider Knowledge Base• Patient/Family Anxiety• Provider Anxiety• Child Becomes Adult (Autonomy)
Ideal State
• Transition Starts at the Right Time• Standardized, Proactive Process• Patient Familiar with Facility• Transition Plan Content• MD-MD Relationship• Post-Transition Follow-up
Priority Setting
• Transition of Care Conference with Multidisciplinary Input
• Potential insurance issues for adulthood identified and addressed
• Transition Document Created / Housed in the EMR
PDSA Cycle 1
• 20 year old female with vasculitis, multiple inpatient stays at Children’s and Adult Hospitals,– Primary Care had transitioned, Subspecialty Care had not
• Inpatient Transition Planning Assessment Tool– 25 minutes for interview– Could be done without preparation,
• The patient preference sheet would be better with additional time
– All but 1 question answerable– Multiple questions revised / rearranged– Moved “Recommendations” into a new 3rd section– Overall very positive experience
Successes and challenges • Ideal Process = Roadmap for Future
Efforts• Engaged Pediatric and Adult Providers
– Including Project Sponsors (Dept Leaders)
• Sparking New Projects
• EHR Implementation• Alignment
– With other institutional efforts– With outpatient efforts
• Broad tracking / data collection• Sustainability
Future plans
• Additional Transition Planning PDSA cycles• Ongoing Alignment of Inpatient / Outpatient Transition Efforts• National Survey of Children’s Hospitals
Dissemination• DOM Grand Rounds 2/2015, seeking other opportunities
Potential Directions• High-quality video introducing patients / families to adult
hospital• Educational activities for adult and pediatric providers• Alignment with other institutions• Systems for data collection / reporting
Thanks!
• UW Inpatient Transition Team• Wisconsin DHS / Waisman Center– Wisconsin Children and Youth with Special Health
Care Needs (CYSHCN) Youth Health Transition Quality Improvement Grant