Partners with HRTW: Improving Transition Outcomes

Brief History CHOICES –Build strong interagency partnerships across public and private systems of care for children and youth with special health care needs –Improve systems for coordination of care in both Shriners Hospitals and State Title V CSHCN programs –Integrate transition into the mission to improve interagency partnerships and care coordination

Brief History CHOICES : –KY, SC, OH and TN were involved in collaboration activities – 3 states with Shriners Hospitals and TN without CHOICES : –Project responded to MCHB and SHC requests to expand focus of interagency collaboration to include Vocational Rehabilitation –Title V Care Coordinator at Shriners Hospital: FL, IL, KY, MN, MO, OH, OR, SC, UT, WA

CHOICES –Joined the HRTW projects and served as platform for a series of three national conferences on transition Washington, DC, Chicago, Charleston, SC –4 state/hospital demonstration projects KY, UT, FL, and HI Brief History

KY TEACH –Partnered with this HRTW demonstration project at state/hospital level in Kentucky to change practice within one state and hospital HRTW National Centers –Collaborated with HRTW National Centers to integrate what had been learned from HRTW demonstration projects into best transition practices across 21 Shriners Hospitals Brief History

Outcomes: Clinical Guidelines Clinical Guidelines developed and adopted across the system regarding recommended best transition practices Tools and resources shared across hospital system and on HRTW web site Focus on improving transition services for both individuals and populations

Clinical Guidelines Focus on developmental touch points –Starting early –Providing developmentally appropriate education and referral to resources (infancy, early childhood, entry into elementary, middle and high school) –Tracking progress over time –Coordinating care throughout the transition years beginning at age 14 –Focus on appropriate referral and hand off to adult health care

Outcomes: Special Programs Transition camps Week-end events/resource fairs Proms Sporting events Teen support groups Work programs Learning independent living skills

Outcomes Focus on quality improvement and outcomes –Exit survey What was delivered –Information –Education –Referral –Post graduation follow-up survey How are our youth doing following discharge? What could we have done better?

Next Steps Improving electronic documentation Developing Free-Mind system for organizing transition resources and making available to interested hospitals Expanding quality improvement and outcomes evaluation activities across all hospitals Continuing to encourage strong interagency partnerships and improved care coordination focused on improving transition outcomes

Contact Information Betty Presler – –Shriners Hospitals for Children 1900 Richmond Road Lexington, Kentucky 40502