Health Care Transition iTransition-Health : Self-Management Skills for Health Care

Health Care Transition Health Care Transition iTransition-Health: Self-Management Skills for Health Care iTransition-Health: Self-Management Skills for Health Care THE GOVERNOR’S INTERAGENCY TRANSITION COUNCIL FOR THE GOVERNOR’S INTERAGENCY TRANSITION COUNCIL FOR YOUTH WITH DISABILITIES YOUTH WITH DISABILITIES November 16, 2013November 16, 2013

Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration

Antoinette W. Coward, MS, MCHESHealth Care Transition Coordinator

Office for Genetics and People with Special Health Care Needs

Prevention and Health Promotion Administration11/16/2013

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MISSION AND VISIONMISSION AND VISION

MISSION• The mission of the Prevention and Health Promotion Administration is

to protect, promote and improve the health and well-being of all Marylanders and their families through provision of public health leadership and through community-based public health efforts in partnership with local health departments, providers, community based organizations, and public and private sector agencies, giving special attention to at-risk and vulnerable populations.

VISION• The Prevention and Health Promotion Administration envisions a future

in which all Marylanders and their families enjoy optimal health and well-being.


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iTransition-HealthiTransition-Health

MISSION•The mission of the Office for Genetics and People with Special Health Care Needs’ Health Care Transition Program (iTransition-Health) is to promote and improve health care transition services for Maryland youth and young adults with special health care needs (12 to 26 years old).

VISION

•The Health Care Transition Program envisions a future in which Maryland youth and young adults with special health care needs in partnership with their families and providers has established health care transition plans leading to continuous health care access.


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INFORMATION WE’LL INFORMATION WE’LL COVERCOVER

Health Care Transition

Increasing Youth Involvement in Managing Health and Wellness

Resources to Support Health Care Transition


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HEALTH CARE TRANSITIONHEALTH CARE TRANSITION

Health care transition is helping young people with special health care needs plan their move from the child-centered health care system to the adult-centered health care system. Some ways that this is done include:

• Current doctors and health care providers discussing changing health care needs as youth become adults and eventually see adult providers

• Doctors, other health care providers, and families encouraging youth development toward self-management skills and knowledge

• Families, youth, and providers working together on a written Transition Plan(s)


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DEFINITION FOR CSHCNDEFINITION FOR CSHCNChildren with Special Health Care Needs (CSHCN) are children; children who happen to need extra care

Who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions

Who require health and related services of a type or amount beyond that required by children generally

Maternal and Child Health Bureau, US Department of Health and Human Services, (Cooperative Agreement MCU-06 MCP1), July 1,1998


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Children with Special Health Children with Special Health Care Needs in MarylandCare Needs in Maryland

244,000 children have special health care needs in Maryland, which is the equivalent of enough children to fill 3.5 Baltimore Ravens Stadiums!


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… and almost 1 in 4 households with children (23.1%) have at least one CYSHCN

18.2% have one CYSHCN

4.9% have two or more

CYSHCN


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2009/10 National Survey of Children with Special Health Care Needs Maryland Profile

Groups less likely to receive services necessary for a

successful transition:

•Black YSHCN

•YSHCN ages 15-17 years

•YSHCN with emotional, behavioral or developmental

issues

•YSHCN with inadequate insurance

•YSHCN without a medical home

•YSHCN with single mothersMaryland

rank: 40

Youth Health Care Transition For YSHCN in Maryland Data Sheet (data from NS-CSHCN)

Youth Transition to Adulthood


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HEALTH TRANSITION HEALTH TRANSITION SURVEY AREASSURVEY AREAS


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2012 MARYLAND TRANSITIONING 2012 MARYLAND TRANSITIONING YOUTH PARENT SURVEYYOUTH PARENT SURVEY

Almost 49% of YSHCN families report having participated in some type of transition planning for their child; of these:

• 72% participated in transition planning through their child’s IEP only

• 2.7% participated in health care transition planning only

• and 25% participated in transition planning through their child’s IEP and also participated in health care transition planning


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TRANSITION PLANNING TRANSITION PLANNING

• Developing a transition plan for YSHCN is an important tool in the process of moving to adulthood

• Including health care in the transition plan, or developing a separate health care transition plan with care providers, is crucial.

• Health care transition planning should be done by youth, families, and providers.


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INDEPENDENCE WITH INDEPENDENCE WITH SUPPORTSUPPORT

Health and WelIness 101: The Basic Skills to support independence:

Knowledge of Health Issues/DiagnosisBeing PreparedTaking ChargeAfter Age 18 Skills

Source: Got Transition?


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If possible, teens and young adult should be able to:

Understand their own condition and the treatment or intervention needed – “I have cerebral palsy because I lost oxygen

at birth… I need help with…” Explain their condition and needed treatment or

intervention to others – “I am on three medications for spasticity.”

Source: Transition to Adult Health Care: A Training Guide in Two Parts. Waisman Center, University of Wisconsin-Madison


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Monitor their health status on an ongoing basis – “I use my communication device to let others know how I am feeling.”

Ask for guidance from their pediatric health care providers on how and when to make the move from pediatrics to adult care – “I’m going to ask my pediatrician- when should I start seeing a family practice doctor for my general care instead of a pediatrician?”



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Learn about the systems (and the importance of them) that will apply to them as adults, such as health insurance, social security and other programs; as well as issues like guardianship and power of attorney for health care –

“I have applied for medical assistance through Social Security for now because I have a disability and I need to be able to get medical



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Identify both formal and informal advocacy services and supports they may need in order to be as independent as possible while at the same time using trusted advisors and mentors –

“I ask my parents for advice because they have known my medical care the longest.”

Remember to Reward Efforts!



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Start small. Start slow. Start Start small. Start slow. Start now!now!

How do you prepare your teens to meet the challenges of adult health care? By using ordinary, every day teaching opportunities and lots of practice.

“Just because a thing is inconceivable doesn’t mean it’s impossible.” – Lewis Carroll



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•Compare your answers with your family. They might be surprised what you know or what you want to learn.•Work on a plan to increase your health care skills. Share with the medical team the skills that you are working on.•It takes time and practice to learn and demonstrate these skills. Best time to start, is today!

www.gottransition.org

Yes I do this

I want to do this

I need to learn how

Someone else will have to do this - Who?

3. My child knows his/her health and wellness baseline

(pulse, respiration rate, elimination habits)

4. My child knows health symptoms that need quick medical attention.

5. My child knows what to do in case he/she have a medical emergency

BEING PREPARED 6. My child carries his/her health

insurance card everyday7. My child carries his/her important

health information with me everyday (i.e.: medical summary, including medical

diagnosis, list of medications, allergy info., doctor’s numbers, drug store number, etc.)

TAKING CHARGE

Yes I do this

I want to do this

I need to learn how


8. My child calls for his/her my own doctor appointments.

9. My child knows he/she has an option to see the doctor by him/herself.

10. Before a doctor’s appointment my child prepares written questions to ask.

11. My child track his/her own appointments & prescription refills expiration dates.

12. My child calls in his/her own prescriptions refills.

Yes I do this

I want to do this

I need to learn how


13. My child has a part in filing medical records and receipts at home.

14. My child pays for the co-pays for medical visits.

15. My child co-signs the “permission for medical treatment” form (with or without signature stamp) or can direct others to do so).

16. My child helps monitor his/her medical equipment so it’s in good working condition (daily and routine maintenance).

AFTER AGE 18

Yes I do this

I want to do this

I need to learn how


17. My child and our family have a plan so he/she can keep my healthcare insurance after turning 18 and 26.

18. My child will be prepared to sign his/her own medical forms (HIPAA, permission for treatment, release of records)

19. My child and our family have discussed and plan to develop a legal Power of Attorney for health care decisions in the event health changes and he/she is unable to make decisions for them self. (Everyone in the family should have one!)


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RESOURCES FOR YOUTH AND RESOURCES FOR YOUTH AND YOUNG ADULTSYOUNG ADULTS

AGES 12 – 14 “New Responsibilities” AGES 15 – 17 “Practicing Independence” AGES 18 & UP “Taking Charge

““Youth2YoungAdult” Care NotebookYouth2YoungAdult” Care Notebook http://cshcn.org/planning-record-keeping/teen-care-

notebook

This resource is on the flash drive bracelets you received today.

It can help youth/ young adults manage aspects of their own health care.

It contains pre-made, fillable forms for:

• Medications• Appointment Logs• Care Schedule• Home Care

Providers• Hospital Information• Insurance/Funding

Sources form• Equipment and

Supplies List• And more!

http://healthytransitionsny.org/skills_media/tool_show or google “Healthy Transitions New York”

CIRCLE OF SUPPORT VIDEOCIRCLE OF SUPPORT VIDEO


SCHEDULING AN APPOINTMENT SCHEDULING AN APPOINTMENT


MyMedSchedule.com https://secure.medactionplan.com/mymedschedule/index.htm

Maryland Transitioning Youth http://www.mdtransition.org/


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RESOURCES FOR PARENTS, FAMILIES RESOURCES FOR PARENTS, FAMILIES AND CAREGIVERSAND CAREGIVERS

My Heath Care NotebookMy Heath Care Notebook http://fha.dhmh.maryland.gov/genetics/SitePages/care_notebook.aspx

This resource is also on the flash drive bracelets you received today.

It can help parents manage aspects of their child and or youth’s health care.

It contains pre-made, fillable forms

Maryland Children and Youth with Special Health Care Needs Resource Locator http://specialneeds.dhmh.maryland.gov

http://www.gottransition.org/families-information or google “Got Transition?”

Transition to Adult Health Care: A Training Guide in Two Partshttp://www.waisman.wisc.edu/wrc/pdf/pubs/TAHC.pdf

http://new.dhh.louisiana.gov/assets/docs/OCDD/publications/EmergencyPreparednessTheTakeandGoEmergencyBook.pdf


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RESOURCES FOR PROVIDERSRESOURCES FOR PROVIDERS

http://www.gottransition.org/provider-information OR google “Got Transition?”

Prevention and Health Promotion Administration[Date]

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http://www.gottransition.org/6-core-Elements-Table or google http://www.gottransition.org/6-core-Elements-Table or google “Got Transition?”“Got Transition?”

Six Core Elements of Health Care Transition Six Core Elements of Health Care Transition Pediatric Health Care Setting

1. Transition Policy2. Transitioning Youth

Registry3. Transition Preparation4. Transition Planning5. Transition and

Transfer of Care6. Transition Completion

Adult Health Care Setting

1. Young Adult Privacy and Consent

2. Young Adult Patient Registry

3. Transition Preparation4. Transition Planning5. Transition and

Transfer of Care6. Transition Completion

http://www.gottransition.org/UploadedFiles/Files/HCTClinicalReporteversion27June2011.pdf Supporting the Health Care Transition

from Adolescence to Adulthood in the Medical Home

Health Care Transition AlgorithmPayment for Health Care TransitionWork

•For YSHCN who require periodic chronic condition management (CCM) visits, health care transition (HCT) planning and preparation are to be included in these visits – can be billed using CPT codes 99214 or 99215 (prolonged encounter codes);

•For care plan oversight billing (provider activities that take place outside of office encounters with the patient – i.e. phone calls to prospective adult providers, conversations with the youth and family regarding transition plans, or communicating with community agencies involved in the youth’s transition) use care plan oversight CPT codes 99374 (15-29 minutes) or 99375 (≥30 minutes)

Source: Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics 2011; 128; 182. http://pediatrics.aappublications.org/content/128/1/182.full.html

Sample Health Care Transition Action Plan http://www.gottransition.org/UploadedFiles/Files/4.1_Transition_Action_Plan.pdf -

Link to document


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Prevention and Health Promotion

AdministrationAntoinette W. Coward

[email protected] 410-767-5602

http://phpa.dhmh.maryland.gov/http://phpa.dhmh.maryland.gov/

http://phpa.dhmh.maryland.gov

Prevention and Health Promotion Administration[Date]

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Prevention and Health Promotion

Administration

Health Care Transition iTransition-Health : Self-Management Skills for Health Care

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