1. Transition to Adulthood: Future Directions in Professional Education
Kitty O’Hare, MD
Internal Medicine-Pediatrics
Assistant Professor, Harvard Medical School

2. Disclosures
I have no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

3. You all get the idea by this point- we need to start early and view transition as a process over time. Today I am focusing our attention on a key building block of successful transitions- educated, informed providers

4. Educate: Latin “educere”- to lead forth
Identity as a teacher from a family of teachers
Merriam-Webster Dictionary

5. Agenda Review the literature
Examples of educational models and curricula
Apply educational theory to transition
GME- focus on residency
Not doing patient education today
IM, Peds, FM more the focus (less surgery, psych)

6. Let us pick up our books and our pens
Let us pick up our books and our pens. They are our most powerful weapons.
Malala yousafzai

7. 2002 Consensus Statement
Identified 6 priorities for improving young adult transitions, including:
“Train primary care providers in transition services”
AAP/AAFP/ACP-ASIM. A Consensus Statement on Health Care Transitions for Young Adults With Special Health Care Needs. Pediatrics 2002; 110:

8. 2011 Consensus Statement
Identified 6 areas for quality improvement, including:
“Promotion of training and clinical experience on transition and transfer of youth and young adults (both with and without special needs) for trainees in all medical fields.”
Transitions Clinical Report Authoring Group, Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home. Pediatrics 2011; 128:
2008 IOM report- need more adolescent training

9. Internists’ Perspectives on Transition
Random survey of U.S. board-certified Internists
Asked to name and rank their concerns about transition
2 out of 5 top concerns related to training
Peter NG et al. Transition from Pediatric to Adult Care: Internists’ Perspectives. Pediatrics 2009; 123:

10. Item Mean Likert Rating Category Wilcoxon Rank
Internists may not have the training in congenital and childhood chronic illness to prepare them to manage them beyond childhood.
2.86
Medical competency 1
It is difficult to care for patients with cerebral palsy or mental retardation if the family does not stay involved.
Family involvement
It can be difficult to meet psychosocial needs of young adults, especially those living with chronic illness
2.77
Psychosocial needs
Some patients may need a superspecialist to manage complex problems (eg, complex congenital heart disease).
Internists often lack training in adolescent medicine, adolescent development, and adolescent behavior.
2.63

11. Barriers to Care: Internists vs Pediatricians
Training as a factor limiting ability to care for young adults with childhood-onset chronic disease
Internists: Ranked 4 out of 9
Pediatricians: Ranked 6 out of 9
Omukura MJ, et al. Physician Views on Barriers to Primary Care for Young Adults With Childhood-Onset Chronic Disease. Pediatrics 2010; 125:e748-54).

12. Comfort with Childhood-Onset Chronic Disease
Survey of 1288 U.S. internists and pediatricians
Assessed comfort with providing primary care for patients with sickle cell disease or cystic fibrosis
Okumura MJ, et al, Comfort of General Internists and General Pediatricians in Providing Care for Young Adults with Chronic Illnesses of Childhood. J Gen Intern Med 2008; 23:

13. Internists
=509
Pediatricians
=739
P Value
Hypertension
91%
31%
<0.001
Asthma
85%
86%
0.9
Diabetes mellitus, Type 1
68%
44%
Depression
54%
29%
Chronic pain
43%
16%
Sickle cell disease
32%
35%
0.3
Complex congenital
heart disease
42%
Cystic fibrosis
15%
38%

14. Internists
=515
Pediatricians
=751
P Value
Proportion treated CF in residency
78%
96%
<0.001
Proportion treated SCD in residency
94%
99%

15. Odds Ratio for Comfort to Treat in Primary Care
Internists
Pediatricians
#CF patients treated in residency
1.5
1.2
#SCD patients treated in residency
1.8
1.4

17. Resident Comfort with Outpatients
Proportion of PEDRs and IMRs who were comfortable with outpatient management of childhood-onset chronic disease.
-Patel and O’Hare 2010
Patel MS and O’Hare K. Residency Training in Transition of Youth with Childhood-Onset Chronic Disease. Pediatrics 2010; 126 S3:S190-3.

18. Likelihood to Provide Care after Residency
Proportion of PEDRs and IMRs who were likely to care for patients with specified childhood-onset chronic disease after the completion of residency.
Patel MS and O’Hare K. Residency Training in Transition of Youth with Childhood-Onset Chronic Disease. Pediatrics 2010; 126 S3:S190-3.

19. Adolescent Medicine Training in 145 Pediatric Residency Programs
14%
17%
33%
37%
49%
50%
IM RRC talks about handoffs but typically refers to inpatient/SNF/outpatient transfers
Chronic Illness
Handoffs to Adult Care
Fox HB, et al. Adolescent Medicine Training in Pediatric Residency Programs. Pediatrics 2010; 125:

20. Adolescent Medicine Training in 145 Pediatric Residency Programs
14%
17%
33%
37%
49%
50%
IM RRC talks about handoffs but typically refers to inpatient/SNF/outpatient transfers
Chronic Illness
Handoffs to Adult Care
Fox HB, et al. Adolescent Medicine Training in Pediatric Residency Programs. Pediatrics 2010; 125:

21. Pediatric Resident Education in CSHCN
Nazarian B, et al. Identifying What Pediatric Residents Are Taught About Children and Youth With Special Health Care Needs and the Medical Home. Pediatrics 2010; 126: S183-9.

22. South Carolina: Resident Preferences for Transition Curriculum
Mennito S. Resident preferences for a curriculum in healthcare transitions for young adults. South Med J 2012; 105:462-6.

23. University of Alabama: Development of a Transition Course
Key insights: 1. Need to include the voices of patients and families 2. Use of faculty from various professions and specialties to model interdisciplinary care 3. Insight that problems specific to transition offer into contemporary health care financing
Hagood JS, et al. A course on the transition to adult care of patients with childhood-onset chronic illnesses. Acad Med 2005; 80:352-5.

24. He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.
William Osler

25. Harvard Longwood Med-Peds Crossover Curriculum
Authors: Zadok Sacks MD, Anna Volerman MD, Niraj Sharma MD MPH
Learners: Med-Peds, Pediatrics and Internal Medicine residents
Format: Resident report conferences featuring guest faculty from the opposite discipline (e.g. adult cardiologist at pediatrics report)

26. Feedback from Pilot (n=70 IM residents)
Quantitative
Qualitative
87% had no prior training related to the transitioning of YSHCN
99% stated that hearing from pediatrics subspecialists about these topics enhanced their learning
98% felt that the CC adds to their education
“I feel much more knowledgeable on [inflammatory bowel disease] and [cystic fibrosis] and would feel more comfortable when taking care of adult patients with those diseases.”
“I will trust a sickle cell patient to tell me what dose of pain meds works for them in a pain crisis.”
“[I will be] more sensitive to [the] transition years.”

27. First Crossover Grand Rounds

28. Brigham & Women’s/Boston Children’s Hospital Transition to Adult Care Conference
Authors: Kitty O’Hare, MD and Niraj Sharma, MD MPH
Learners: Physicians, nurses, social workers, trainees
>200 on list-serv; across Massachusetts and Rhode Island
Format: Monthly interdisciplinary conference
Attendees report making new collaborations and changing practice

29. 2014-15 Themes Transition ethics Clinical services
Patient/Family perspectives
Research

30. 2014-15 Themes Transition ethics Clinical services
Young adult ward & consult service
Adult physiatry
Pain team
Spina Bifida
Neurology
Patient/Family perspectives
Research

31. 2014-15 Themes Transition ethics Clinical services
Patient/Family perspectives
Got Transition? national youth spokesperson
Parent video project
Research

32. 2014-15 Themes Transition ethics Clinical services
Patient/Family perspectives
Research
Health plan data
A novel developmental transition assessment tool

33. Boston Children’s Hospital Primary Care
Author: Kitty O’Hare, MD
Learners: Pediatrics and Med-Peds residents
Format: Continuity clinic teaching case: a 17yo with Down Syndrome
1. Transition tools
2. Sexuality
3. Guardianship/End of Life
4. Education/Vocation/Housing
5. Insurance/SSI/Financial Planning
Transition Jeopardy
Yale has a primary care curriculum for Peds and MP

34. Harvard Medical School Tutorial
Authors: Niraj Sharma, MD MPH
Learners: Medical students
Format: Small group learning
Case: a 19yo with cystic fibrosis
1. The patient
2. The parent
3. The pediatric provider
4. The adult provider

35. AAMC MedEdPORTAL Author: Laurie Fishman, MD
But Tommy Likes It Here: Moving to Adult Medicine MedEdPORTAL Publications;
Learners: Healthcare professionals, trainees
Format: Cases in small group format
Only MedEdPORTAL entry on transition

36. MUSC Transition Elective
Author: Sarah H. Mennito, MD MSCR
Learners: Med-Peds residents
Format: Month-long ambulatory rotation
Subspecialty clinics, literature review, case review, project

37. Baystate Authors: Matthew Sadoff, MD
Learners: Pediatrics, Internal Medicine, and Med-Peds residents
Medical students
Format: Clinical rotation for children with medical complexity
Approach to children with medical complexity
Sadof M, et al. The “HEADS AT” Training Tool for Residents: A Roadmap for Caring for Children With Medical Complexity. Clin Pediatr 2014.

38. University of South Florida
Author: Janet Hess, DrPH, MPH, CHES
Learners: Pediatric and Med-Peds residents
Format: Pilot QI initiative
Multi-level intervention
1. Didactic session
2. Patient transition education materials made available in clinic
3. Transition tool made available in the EHR

39. Children’s Mercy Hospital and Clinics Social Work Education
Author: Terri Hickam, LCSW, LSCSW, CCM
Learners: Social workers
Format: Guardianship training course for staff
Establishing scope of practice for social workers in a team-based approach to transition

40. Duke Children’s ATLAS: Adolescents Transitioning to Leadership and Success
Authors: Gary Maslow, MD MPH &
Amanda Rozycki, MSW
Learners: Pediatrics residents, medical students, college students
Format: Monthly support group for YSHCN

41. AnMed, South Carolina Medical Students as Transition Coaches for YSHCN
Authors: Nathan F. Bradford, MD and Brian Mulroy, DO
Learners: 3rd Year Medical students
Format: Students assigned to coach a YSHCN as they are leaving pediatrics to enter family medicine

42. Got Transition? Authors: www.gottransition.org
Learners: Physicians, practicing and in training
Format: Dr. Right/Dr. Knotright YouTube videos examples of how transition discussions can be done well (or poorly)

43. Illinois Chapter of the AAP Online CME and MOC Part IV
Authors: Illinois Chapter of the AAP
Learners: Practicing Pediatricians, Internists and Family Medicine physicians
Format: Web-based CME

44. FloridaHATS Training for Health Care Professionals
Authors: FloridaHATS
Learners: Physicians and Allied Health Professionals
Format: 10 online modules for CME/CE
They have a great collection of other transition educational resources not included here

45. University of Florida Online graduate certificate in transition education
Authors: University of Florida College of Education
transition/certificate-program/
Learners: Allied health professional students
Format: Online fee-for-enrollment certificate program

46. CHIPRA Massachusetts Medical Home Collaborative
Authors: NICHQ, Boston Children’s Hospital, Massachusetts Health Quality Partners, MassHealth and the University of Massachusetts Medical School
Learners: 13 inter-disciplinary teams from primary care pediatrics
Format: In-person learning sessions and conference calls

47. Education is the most powerful weapon which you can use to change the world.
Nelson Mandela

48. 2014 Match Data
Open intern positions
NMPRA 2014 Match Data,

49. Physician Education Training Requirements
Level of Training
Adolescent Medicine
Care Handoffs
Complex Care/Chronic Disease Management
Transition to Adulthood
UME
Exposure
Yes No
GME
Peds
1 month IM
Med-Peds FM
MOC
Compiled by Sawicki GS, O’Hare K, Antonelli R, Sharma N
MedEd Portal- exactly 1 transition to adulthood case as of 2/27/13, by Dr. Laurie Fishman of BCH
Sharma N, O'Hare K, Antonelli RC, Sawicki GS. Acad Pediatr Mar-Apr;14(2):120-7.

50. Future of Physician Education
UME
Include teaching on long-term survival of disease, and exposure to youth & families as expert faculty
GME
Residents & fellows must learn to care for long-term survivors and about transition processes
MOC
Practicing physicians should learn how to implement care for these patients into their practices
Expand education of non-MD clinicians in transition care
Sharma N, O'Hare K, Antonelli RC, Sawicki GS. Acad Pediatr Mar-Apr;14(2):120-7.

51. Future of Physician Education
GME
Residents & fellows must learn to care for long-term survivors and about transition processes
Expand education of non-MD clinicians in transition care
Sharma N, O'Hare K, Antonelli RC, Sawicki GS. Acad Pediatr Mar-Apr;14(2):120-7.

52. NAS Milestones www.acgme.org
Internal Medicine
Pediatrics
11. Transitions patients effectively within and across health delivery systems.
Coordinates care within and across health delivery systems to optimize patient safety, increase efficiency and ensure high quality patient outcomes
Anticipates needs of patient, caregivers and future care providers and takes appropriate steps to address those needs
Role models and teaches effective transitions of care
PC3. Provide transfer of care that ensures seamless transitions
Adapts and applies the template without error and regardless of setting or complexity; internalizes the professional responsibility aspect of hand-off communication, as evidenced by formal and explicit sharing of the conditions of transfer (e.g., time and place) and communication of those conditions to patients, families, and other members of the health care team
Other competencies address care plans, interdisciplinary collaboration, and care coordination

53. Family Medicine C-1 Develops meaningful, therapeutic relationships with patients and families
Has not achieved Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
Recognizes that effective relationships are important to quality care
Creates a non-judgmental, safe environment to actively engage patients and families to share information and their perspectives
Effectively builds rapport with a growing panel of continuity patients and families Respects patients’ autonomy in their health care decisions and clarifies patients’ goals to provide care consistent with their values
Connects with patients and families in a continuous manner that fosters trust, respect, and understanding, including the ability to manage conflict
Role models effective, continuous, personal relationships that optimize the well-being of the patient and family

54. Bloom’s taxonomy
Knowledge “the recall of specifics and universals, the recall of methods and processes, or the recall of a pattern, structure, or setting.”
Comprehension  “a type of understanding or apprehension such that the individual knows what is being communicated and can make use of the material or idea being communicated without necessarily relating it to other material or seeing its fullest implications.”
Application “use of abstractions in particular and concrete situations.”
Analysis “breakdown of a communication into its constituent elements or parts such that the relative hierarchy of ideas is made clear and/or the relations between ideas expressed are made explicit.”
Synthesis “putting together of elements and parts so as to form a whole.”
Evaluation “judgments about the value of material and methods for given purposes.”
Benjamin Bloom 1956
Benjamin Bloom et al. Taxonomy of Education Objectives, As quoted in the Vanderbilt University Center for Teaching.

55. Bloom’s Taxonomy for Health Care Transition
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Attitudes toward successful transitions
Skills to transition
Knowledge of transition

56. Knowledge Define Transition to Adulthood Define CYSHCN
Pathophysiology of childhood-onset chronic conditions
Adolescent health screening guidelines
This has been most of the focus
Knowledge

57. Knowledge Describe barriers to transition
Describe the 6 core elements of transition
Understand how disease changes from childhood to adulthood
Understand principles of health and wellness
This has been most of the focus
Comprehension

58. Skills Develop transition policies
Build registries and develop EHR tools
Assess patients’ readiness to transition
Develop care plans and other communication tools
Transfer care effectively
We’re getting there
Application

59. Skills Quality improvement Measure outcomes
Evaluate programs and curricula
We’re getting there
Analysis

60. Attitudes Care coordination Behavioral health integration
Patient/family partnerships
Team-based care
Inter-professional collaboration
Cost-effectiveness
Synthesis

61. Attitudes Disseminate best practices
Advocate on the local, community, state, and federal level
Enact policies favorable to youth in transition
Change the world
Evaluation

62. Bloom’s Taxonomy for Health Care Transition
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Attitudes toward successful transitions
Skills to transition
Knowledge of transition

63. Acknowledgements Harvard Longwood Med-Peds Residency Program
Weitzman Family BRIDGES Young Adult Program at Boston Children’s Hospital
Harvard Medical School Center for Primary Care
Health Care Transition Research Consortium

64. Contact information
LinkedIn