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Moving From Pediatric to Adult Health Care

 

Current State of HCT in MN

Across the country, less than 30% of youth with special health needs (YSHN) received help preparing for this transition. Research indicates that without HCT preparation, YSNH can experience a loss of services and subsequent decline in health. In Minnesota, 17.5% or 226,402 children and youth under 18 have a special health care need compared to the national estimate of 19.5%. 

 

Improving HCT in MN

Gillette Children’s, in collaboration with the National Alliance to Advance Adolescent Health and Got Transition® and with funding from the Minnesota Department of Health, Children and Youth with Special Health Needs section is taking a leadership role in supporting improvements in the transition from pediatric to adult care.  Our work began 2023 with the launch of the Health Care Transition Learning Collaborative (HCT LC). Over 18 months we brought together a multidisciplinary group of people to develop an understanding of recommended HCT services.  

We learned that clinicians want to support their patients and families with a safe health care transition but often lack organizational resources and support. Coupled with system-level challenges such as a lack of adult providers for transitioning CYSHN and a lack of reimbursement for this time-intensive population, sustainability of health care transition initiatives is limited.     

Our work for the next 3.5 years will address these system-level challenges. The first step is a strategic partnership analysis of Minnesota advocacy, health plan, health system and professional organizations to identify opportunities for HCT education, quality improvement, and systems change. Findings from this analysis will inform a series of annual Project ECHO Learning Sessions and an annual Health Care Transition Summit.  

 

Health Care Transition Resources

 

2023-2024 HCT LC ECHO Session Recordings

Eight, virtual learning sessions utilized the Project ECHO learning model, an “all teach, all learn” approach and offered CME credit. Each 60-minute session included a didactic discussion around a session-specific topic, followed by a case presentation and case discussion. 

After attending this session, participants should be able to: 

  • Describe important definitions related to equity and trauma-informed approaches. 
  • Describe the main principles of Trauma-Informed Care. 
  • Apply Equity and Trauma-Informed approaches within health care transition. 

Didactic Presenter(s):

  • Maria Medina
  • Alyssa Greene 

Session Recording:

After attending this session, participants should be able to: 

  • Assess the current context of health care transition (HCT) outcome evidence. 
  • Describe the American Academy of Pediatrics (AAP)/American Academy of Family Physicians (AAFP)/American College of Physicians (ACP) Six Core element approach and tools for pediatric, family medicine and adult practices. 
  • Describe key lessons learned from implementing HCT performance improvement program in pediatric and adult systems. 

Didactic Presenter:  

  • Patience White

Questions and answers from the session:

Session Recording:

After attending this session, participants should be able to: 

  • Describe ways to engage families and youth on an individual level (e.g., Got Transition’s HCT Family Toolkit). 
  • Describe approaches to support gains in health literacy and autonomy (youth time alone w/ clinician, Transition Readiness Assessment).  
  • Design co-created plans of care. 
  • Apply methods to engage families and youth at the systems level (e.g., Importance of family advisory group, so ‘connect the dots beyond patient’, Family Voices’ FESAT to assess engagement effectiveness) 

Didactic Presenter: 

  • Peter Scal

Session Recording:

After attending this session, participants should be able to: 

  • Explore opportunities for supported decision making and other alternatives to guardianship for adolescents and young adults with neurocognitive challenges.
  • Identify decision-making support options in Minnesota. 
  • Describe processes for guiding decision-making supports.   

Didactic Presenter:

  • Anita Raymond, LISW, CMC - Program Director- Volunteers of America - Minnesota

Session Recording:

After attending this session, participants should be able to: 

  • Outline goals and action steps to ensure a safe transfer from pediatric to adult outpatient care for young adults including finding an adult provider, creating welcome and orientation materials, planning initial visits, and reducing no-show rates. 
  • Identify challenges in ensuring a safe transfer (lack of information, warm hand offs, and lost to follow up) 
  • Implement tools that can help improve transfer and integration into adult care. 

Didactic Presenter:

  • Tisa Johnson-Hooper, Henry Ford Health System 

Session Recording:

After attending this session, participants should be able to: 

  • Employ strategies on how to prepare the office and staff for youth with intellectual and/or developmental disability (IDD) IDD as compared to youth without IDD. 
  • Describe what should be done prior to the first visit to make the first visit easier for the youth with IDD. 
  • Describe what should occur during and after the first visit for youth with IDD (Tool: https://gottransition.org/resource/?tips-integrating-idd-into-practice) 

Didactic Presenter:

  • Chris Hanks, Ohio State University

Session Recording:

 

After attending this session, participants should be able to: 

  • Explain the importance of standardizing the health care transition (HCT) process. 
  • Describe the steps to begin a HCT improvement process in your own practice. 
  • Evaluate an example of implementing Core Element #1: a Transition and Care Policy/Guide. 

Didactic Presenter:

  • Patience White, MD, The National Alliance to Advance Adolescent Health 

Session Recording:

After attending this session, participants should be able to: 

 

 


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  • Identify ways health care can be included in special education transition planning. 

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  • Identify transition tools and resources for clinicians, youth and families, school nurses, and special educators on Minnesota’s Disability Hub. 

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  • Identify innovative Minnesota cross-sector efforts to improve transition to adult health care, post-secondary education, employment, and independent living.  





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Didactic Presenter:

 

 


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  • Alyssa Klein, MS, CRC | Youth Services Coordinator - Minnesota Department of Employment and Economic Development (DEED)- Vocational Rehabilitation Services (VRS)

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  • Heidi Haines, MS, RN, LSN, CPNP - Licensed School Nurse





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Session Recording:

 

 


 

 

Transition Education Summit

The Transition Summit will offer participants valuable insights into enhancing their clinics, hospitals, programs, and overall state practices related to pediatric to adult HCT. These advancements are urgently needed to support the growing number of youths with special health needs aging into adulthood and to ensure safe HCT from pediatric to adult care systems. Presentations will focus on: 

  • Extending the principles of patient and family centered care, trauma-informed care, and health equity to HCT,  
  • Introducing state-level initiatives to advance HCT 
  • Learning from other systems on implementing measurable and sustainable HCT processes 
  • Identifying how your organization can move the dial on HCT.  

AMA PRA Category 1 Credits™ will be offered for participation in the Transition Education Summit. Amount of credit is 6.5 credits.

View recording:

 

 

Questions?

 If you have any questions regarding our work, please contact us at: meganmlutz@gillettechildrens.com.