1. Transitioning from Children’s to Adult Hospital Inpatient Settings Sarah Ahrens, MD Ryan Coller, MD, MPH Jody Belling, RN, MS

2. 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

3. 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”

4. Project History Grant Opportunity MD and NP task force from Internal Medicine, Pediatrics, and Emergency Medicine Late 2013

5. 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

6. 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

7. 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

8. Team Formation, Charter Current Process Ideal Process Pilot Intervention Project Approach Planning Trials Intervention Trials Data Collection Modifications, Spread PDSA CYCLES

9. Team Formation Role Nursing (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

10. Current State Frustration Themes Lack of Process Relationships/Conversations Provider Disagreement Provider Knowledge Base Patient/Family Anxiety Provider Anxiety Child Becomes Adult (Autonomy)

12. 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

14. Priority Setting Transition of Care Conference with Multidisciplinary Input Potential insurance issues for adulthood identified and addressed Transition Document Created / Housed in the EMR

16. 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 3 rd section – Overall very positive experience

17. 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

18. 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

19. 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