107. PATHWAYS INITIATIVE TO IMPROVE TRANSITION CARE IN A MED-PEDS RESIDENCY PROGRAM

Background Approximately 750,000 adolescents with special health care needs graduate to adulthood annually, often with their health suffering. Less than half receive the services needed for a successful transition. In Illinois the Division of Specialized Care for Children Family Survey revealed that only 18.2% of youth ages 14-21 received transition services. A recent review demonstrated that almost two thirds of HCT evaluation studies had statistically significant positive outcomes. Another study demonstrated that providing HCT services resulted in a 28% reduction in per member per month total cost driven by reductions in hospitalization and ED visits. Aim Statement 1. Increase HCT services for youth and young adults with special health care needs (YASHCN) in a Med-Peds residency practice (10% per year). 2. Increase HCT consultations for YASHCN (10% per year). 3. Improve HCT knowledge, attitudes and practices among Med-Peds residents. (improve annually). 4. Provide Med-Peds residents with a longitudinal QI project aligned with ACGME requirements. Interventions PATHways is a residency-based HCT consultative service founded to improve health for YASHCN and provide HCT education to residents. PATHways’ QI initiatives are modeled after Gottransition's Six Core Elements. A HCT policy was disseminated. EMR tools were developed to assess HCT skills and create portable health summaries. A registry of over 200 YASHCN aged 14-26 in the practice was created. Formal HCT education was provided to residents through HCT consultations. Measures 1. Baseline and annual follow up HCT knowledge, attitude, and practices survey of residents 2. Baseline and annual follow up audits of patients in the HCT registry addressing key elements (readiness assessment, HCT planning, creation of portable health summaries) 3. Tracking of consultations: Requesting services, diagnoses, HCT services provided. Results 33 consultations were provided over 18 months and were received from 9 different services with Pediatrics comprising 70%. Autonomy planning and completion of portable healthcare summaries comprised the majority of consults (80%). Consultations also aided in guardianship (43%), insurance and income support planning (67%), and identifying adult providers (20%). Residents surveys demonstrated increased HCT knowledge. Residents correctly identified the ages to introduce HCT, begin HCT planning, and prepare for transfer (scores increased by 8%, 21%, and 8%, respectively). They were able to identify specific tools for HCT including the clinic's policy and registry. After one year, 42% of residents stated that they addressed HCT readiness often in their practice, increased from 18%, and no residents reported not ever addressing HCT, improved from 38%. Residents reported providing more frequent guidance on education, insurance planning, registering for adult services, guardianship assessment, and identifying adult providers. Residents reported feeling more empowered and engaged in caring for YASCHN. Baseline and follow up chart audits demonstrated that readiness assessment improved from 10 to 50%, transition planning improved from 20 to 60% and creation of portable health summaries improved from 5 to 45%. Conclusions and Next Steps The PATHways initiative is a feasible way to improve HCT for YASHCN and resident HCT knowledge, attitudes and practices. Next Steps: 1. Utilize the EMR's new feature, Slicer Dicer for transition registry management and chart audits. 2. Mailers and EMR messages will be sent to all patients in the transition registry directing them to schedule a HCT appointment. 3. Continue to raise awareness about the PATHways consultation services.