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Health Care Transition Resources

Successful pediatric to adult healthcare transition is a Minnesota and national priority. Evidence-driven best practice resources from the HCT LC and other sources are listed below. If you want to be notified about future HCT LC education and training resources,

From 2023 - 2024 the MN Health Care Transition Learning Collaborative shared best practices and MN and national resources to help build the skills necessary to improve Pediatric to Adult Health Care Transition at a practice level. Recordings for each session and for the Second Annual Summit are available for viewing below.  

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: 

  • Identify ways health care can be included in special education transition planning. 
  • Identify transition tools and resources for clinicians, youth and families, school nurses, and special educators on Minnesota’s Disability Hub. 
  • Identify innovative Minnesota cross-sector efforts to improve transition to adult health care, post-secondary education, employment, and independent living.  

Didactic Presenter:

  • Alyssa Klein, MS, CRC | Youth Services Coordinator - Minnesota Department of Employment and Economic Development (DEED)- Vocational Rehabilitation Services (VRS)
  • Heidi Haines, MS, RN, LSN, CPNP - Licensed School Nurse

Session Recording:

 

Second Annual Health Care Transition Summit | June 13, 2024

The 2nd annual HCT Summit offered 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. Presentation focused 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.   

 

00:00:00 Welcome and Introduction 

  • Tori Bahr, MD | Wendy Berghorst | Meredith Hintze | Micah Niermann, MD 

00:10:00 Incorporating Youth and Family Experience to Ensure Patient- and Family- Centered Health Care Transition 

  • Carolyn Allshouse | Debbi Harris | Brianna Inkster | Kaya Inkster | Reid Landay | Michelle Thomsen 

01:13:00      Applying Principles of Equity and Trauma-Informed Care into Practice 

  • Alex Boucher, MD | Alyssa Greene, LPCC | Maria Medina, MPH 

02:27:40      Lunch and Learn: Happenings at the State and National Level 

  • Wendy Berghorst | Peggy McManus, MHS | Patience White, MD, MA 

02:54:18     Minnesota Health Care Transition Process Improvement Experience 

  • Michael Peterson | South Lake Pediatrics | Children’s Minnesota | HealthPartners-Regions | UnitedHealthcare 

04:16:30     Innovation and System-Wide Incorporation of Health Care Transition: Children’s Mercy Kansas City 

  • Stephanie Pratt, LMSW 

05:34:25     Summit Wrap Up and Goal Setting 

  • Tori Bahr, MD 
 

Process Improvement Learning Track 2024

In coordination with Got Transition, Gillette Children’s utilized funding from COPIC Foundation to extend the impact of the HCT LC by providing an optional learning track to four organizational teams seeking to improve their current pediatric to adult health care transition process. We used the Model for Improvement (MFI) framework developed by Associates in Process Improvement and Plan-Do-Study-Act (PDSA) cycles to help the teams understand, test, refine and integrate the evidence-driven Six Core Elements of Health Care Transition™ into clinical practice.  

Process improvement learnings from each of the four teams was presented at the 2nd Annual Transition Summit. To view the presentations, advance to 02:53 in the recording (add link).   

First Annual Health Care Transition Summit sponsored by Minnesota Medical Association 

View Recording:  

Pediatric to Adult Healthcare Transition Roundtable -June 14,2022 

Resources  

Got Transition website:  

Got Transition® 

Minnesota Disability HUB 

Disability Hub MN - Home 

Movingtoadulthealthcare.org  

Welcome! - Moving to Adult Health Care 

 

Questions?

 If you have any questions regarding this free continuing education activity, please contact us at meganmlutz@gillettechildrens.com