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