A Team Approach Improves the Transition from Pediatric to Adult Care

Strategize with Your Team

Implementation of a healthcare transition process is not one-size-fits-all. After creation and dissemination of a transition policy, we suggest choosing from a few different strategies to help your team determine which specific core elements to focus on next.

1. Close the most urgent gaps first. If you walk into an emergency department shift as multiple traumas roll in, you’re going to stabilize those patients before moving to the full waiting room. Similarly, if you have multiple Medicaid patients with lupus neph­ritis who are lost to follow-up after age 18 due to loss of insurance, targeting the core elements of transition planning and tracking/monitoring for a narrower, high-risk population may be a good starting point. Of course, tackling the biggest problem first may be resource intensive, but it may also spark immediate buy-in from key stakeholders, such as division leadership.
2. Obtain a quick win. Starting your healthcare transition project with a more attainable short-term goal may not drastically move the needle immediately in terms of changing patient outcomes, but it can boost team morale and motivation and inspire more active long-term engagement to accomplish more aspirational outcomes. If you are targeting regular transition readiness assessments, send a celebratory divisionwide email for every 25 patients who complete a Transition Readiness Assessment Questionnaire. If possible, include a positive patient quote regarding development of self-management skills.
3. Leverage your division or institutional resources. A large variation in administrative, clinical and health IT support exists across rheumatology practices. If you have a full-time, on-site social worker invested in healthcare transition, incorporate them into developing your process map. If, instead, you have excellent medical assistant support, try to boost your transition-readiness screening and transition policy dissemination. Practices with health IT support may build dashboards to facilitate completion of transition processes at the point of care or capture data to populate a patient registry.
4. Align with larger institutional goals or interorganizational networks. Institutions often have a list of high-priority areas for improvement, such as reducing hospital readmissions or decreasing patient safety events. Small institutional grants may be available for projects that align with these goals and can be a great way to quickly garner resources needed for a successful multifaceted healthcare transition process.

Individual practices can also leverage the resources of professional organ­izations through which experience is shared and goals related to the implementation of healthcare transition processes are developed. For example, a number of pediatric rheumatology sites participate in the Childhood Arthritis Rheumatology Research Alliance Transition Learning Collaborative, which is utilizing quality improvement and implementation science methodology to determine the feasibility, acceptability and impact of transition policy interventions in rheumatology.