rachel bensen, md, mph dana steidtmann, phd yana vaks, md mentor: arnold milstein, md, mph
DESCRIPTION
B ridging T he G ap:. Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Disease. Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH. The Triple Aim. Improving patient experience. Lowering per capita costs. - PowerPoint PPT PresentationTRANSCRIPT
Rachel Bensen, MD, MPHDana Steidtmann, PhD
Yana Vaks, MD
Mentor: Arnold Milstein, MD, MPH
Bridging The Gap:Transition from Pediatric to Adult Care for Young Adults
With Childhood Onset Chronic Disease
The Triple AimImproving patient experience
Lowering per capita costsImproving
population outcomes
“Boot Camp”
Literature Review
Observations, Needs Assessment, Expert Consultation
Prototyping
Model Refinement
Identification of pilot sites
Implementation
Evaluation & Further Refinement
Dissemination of Successful Models
Year 1
Year 2
Beyond
http://cerc.stanford.edu
“I feel like I am a burden to everyone”
“Transition is so serious and so scary”
“When is it going to be my turn to talk?”
“Patients want a life program,not a medical program”
“There is no quarterback”“This is a patient safety issue”
Consensus Statement on Transitions(2002, 2011)
Purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of young people with chronic medical conditions, as they move from child-centered to adult-oriented health care system
Pediatrics Specialized Adult Medical Home
Pediatrics Transition Clinic Adult Care
Remain within the Pediatric System
Transition Processes Now Pediatrics +/-
Transition Preparation or Consult
Adult Care
Spikes in Health Crises
Brousseau et al 2010 (JAMA) Acute Care Utilization and Rehospitalizations for Sickle Cell Disease
Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Disease -
Who are we talking about?
Age: 15-25 years
US: 39.2 million
5-10% (4 million) have serious chronic conditions
0.5 million young adults transition from pediatric to adult care every year
2010 US Census Data
Cerebral palsyType I DiabetesCystic FibrosisCongenital heart diseaseTransplantsRare genetic and metabolic disordersSevere asthma Spina bifidaInflammatory bowel disease LupusSickle Cell DiseaseMuscular Dystrophyand many others…
ConnorAge: 19
Muscular Dystrophy
DianaAge: 22
Cerebral Palsy
GabeAge: 17
Type I Diabetes
= Costly, avoidable hospitalizations & unnecessary suffering
Bridging The Gap:Transition from Pediatric to Adult Care
For Young Adults with Childhood Onset Chronic Disease
Build and support self-management skills
Team-up providers to match care to changing patient needs
Guide patients & families through service changes to avoid care laps
~15% net reduction in annual per capita medical spending for target population
Build and support self-management skills
Guide patients & families through service changes
Tele-mediated specialty support
Ongoing AssessmentDial services up and down
Match individual needsReal time remote check-ins
Prompt responsesAvoid acute crises
Psychosocial
Mental Health
Health Coach1.5 FTE*
Navigator4 FTEs*
Bridge Team• Lead & oversee the Bridge Team• Organize medical care most medically fragile• Provide medical back up• Quality control
• 1-to-1 coaching to motivate and build skills for self management of illness
• Orient to device based self tracking tools• Support during high risk periods• Mentorship
• Point-of-contact during transition• Assess risk factors to match to relevant resources• Transition readiness checklist• Outreach during high risk periods• Educate on what to expect during transition• Mentorship
*Per 300patients
Difficult Period• Medical issues exacerbated
• Being a teenager is tough• Mental health problems surface• Caregiver fatigue Decreased treatment adherence
Mismatched Care• Limited care coordination • Gaps in knowledge & support• Not suited to busy patient lifestyles
Avoidable hospitalization and increased ER use
The Gap• Complex systems are hard to maneuver
• Fear of the unknown• Service changes• Lack of system interoperability
Lapses in care and unnecessary tests
Cha
lleng
esBridging The Gap
Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Illness
Build & Support Self-Management
• Technology-supported: • Health coaching• Treatment for anxiety &
depression• Peer support
Guide Patients & Families
• Navigation services• Transition checklist• Personal Health Record• Link to local resources
• Pull system to ensure stable arrival
Tele-mediated specialty and care coordination support
• Enhance care coordination• Support primary care • Improve access
The Patient
S
oluti
ons
Predicted Gains: Clinical Outcomes Patient & Family Experience Spending 15%
BRIDGE TEAM: Advanced Practice Providers, Navigators, Health Coaches
ONGOING ASSESSMENT Patient segmentation to dial care level up and down
The System The Handoff
Difficult Period• Medical issues exacerbated
• Being a teenager is tough• Mental health problems surface• Caregiver fatigue Decreased treatment adherence
Mismatched Care• Limited care coordination capability• Gaps in knowledge & support• Not suited to busy patient lifestyles
Avoidable hospitalization and increased ER use
The Gap• Complex systems are hard to maneuver
• Fear of the unknown• Service changes• Lack of system interoperability
Lapses in care and unnecessary tests
Cha
lleng
esBridging The Gap
Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Illness
Build & Support Self-Management
• Technology-supported: • Health coaching• Treatment for anxiety &
depression• Peer support
Guide Patients & Families
• Navigation services• Transition checklist• Personal Health Record• Link to local resources
• Pull system to ensure stable arrival
Tele-mediated specialty and care coordination support
• Enhance care coordination• Support primary care • Improve access
S
oluti
ons
Predicted Gains: Clinical Outcomes Patient & Family Experience Spending 15%
BRIDGE TEAM: Advanced Practice Providers, Navigators, Health Coaches
ONGOING ASSESSMENT Patient segmentation to dial care level up and down
The Patient The System The Handoff
ConnorAge: 19
Muscular Dystrophy
DianaAge: 22
Cerebral Palsy
GabeAge: 17
Type I Diabetes
• Remote specialist consults
• Online depression treatment for mother
• Health coach
• Navigator • Navigator • Navigator• Personal Health Record • Personal Health Record
• Remote specialist consults
• Personal Health Record
• Care coordination
• Flexible appointments• Peer support• Ongoing mental health
screening
Bridging The Gap
