This study evaluated a quality improvement initiative to implement a more coordinated transition process for adolescents with chronic illnesses moving from pediatric to adult-focused healthcare using the Six Core Elements framework. They found: 1) Teams reported improved implementation of transition processes over time, especially in transition readiness and transfer of care. 2) The proportion of patients transitioned from pediatric to adult providers doubled from 11% to 27% and the average time between last pediatric and first adult visit decreased from 232 to 146 days. 3) Providers felt the Six Core Elements provided a useful framework and regular meetings between pediatric and adult providers helped build trust to advance the transition process.

1. Improving the Process of Subspecialty Transition
for Adolescents With Chronic Illness
Marybeth Jones MD1
, Marilyn Augustine MD2
, Jackie Doyle MSN ACNP2
Heather Jones LMSW3
, Jean Mack-Fogg RN MS PNP-BC3
, Marcy Odell LMSW4
and Brett W Robbins MD1
1
Departments of Internal Medicine and Pediatrics, 2
Division of Endocrinology, Department of Medicine, 3
Division of Endocrinology, Department of Pediatrics, 4
Division of Pulmonology, Department of Pediatrics
Background
Results
Results
• Poorly coordinated health care transitions (HCTs) for YSHCN
(Youth with Special Health Care Needs) from pediatric to adult
oriented practices result in fragmented care; thus, a more
coordinated approach is recommended by The American
College of Physicians, American Academy of Pediatrics,
American Academy of Family Physicians and The Society for
Adolescent Medicine
• Many YSHCN identify a pediatric subspecialist as their “main
doctor,” but transition processes often are not implemented
into subspecialty care
• The Maternal and Child Health Bureau’s (MCHB’s) National
Health Care Transition Center ‘s Six Core Elements (6CEs)
improved implementation of a standardized transition process
in primary care, but have not been studied in subspecialties
Conclusions
Objectives
Methods
To establish a systematic transition QI initiative in subspecialty
settings using the 6CE, in order to:
1)Increase HCT process implementation
2)Elicit provider feedback regarding this process
3)Increase number and efficiency of completed transfers of
target population (ages 18 – 26 years) to adult settings
Pediatric and internal medicine (IM) representatives formed 3
teams (endocrine, hematology and pulmonology) to meet
monthly with a combined med-peds faculty moderator to
implement 6CE in practice among a target patient population
Outcome Measures
• Team representatives completed a 6CE Process Measurement Tool (PMT)
on T1, T2, and T3 during the initiative period
(April 1, 2014 - August 31, 2015)
• Chart review revealed characteristics of patient transfers between
participating pediatric and adult oriented subspecialists
Summary of Findings
•Teams noted improved implementation of transition processes, with pediatric
participants showing significantly improved PMT results (Table 1)
•Based on PMT results, teams showed the largest improvements in the
specific 6CE processes of transition readiness and transfer of care *
•Providers relayed that the 6CE worked as a framework to move the transition
process forward and “actually get something done”*
•Together, the 3 teams increased the proportion of target patients transferred to
adult providers as compared to baseline by a factor of 2, from 11% to 27%
•The number of days between the last pediatric and first adult visit was
shortened by an average of 90 days (232 vs 146) and reduced below the
target goal of having a gap of no greater than 180 days between providers (
•The average patient age at transfer (21 years old) and average show rate to
the first scheduled adult visit after transfer remained stable (Table 2)
*Data not shown
Table 2: Characteristics of patient transfers from pediatric to adult
oriented subspecialty care after the intervention compared to pre-
intervention period
Endocrine
(Type 1
Diabetes)
Hematology
(Sickle Cell
Disease)
Pulmonology
(Cystic
Fibrosis)
Prea
Postb
Prea
Postb
Prea
Postb
Patient Transfers n = 20 n = 46 n = 1 n = 6 n = 4 n = 9
Target Population n = 191 n = 180 n = 20 n = 26 n = 21 n = 17
% of pediatric patients
(ages 18 – 26) with
disease of focus
transferred to adult
oriented care
10% 26% 5% 23% 19% 53%
p-valued
< 0.01 - < 0.01
Average gap between
last pediatric and first
adult visits (days)
260 187 62 121 137 80
p-valuec
0.38 - 0.16
Average patient age at
first adult visit 21.3 21.8 20.5 20.4 19.9 20.1
p-valuec
0.46 - 0.70
Show rate to first adult
visit after transfer 95% 98% 0% 33% 75% 100%
p-valued
0.47 - 0.15
a
Pre-Intervention Period: (11/1/2012 – 3/31/2014)
b
Post-Intervention Period: (4/1/2014 – 8/31/2015)
c
Calculated using independent measures t-test
d
Calculated based on χ2 test for independence
• The 6CE provide a successful framework for transition across a wide
variety of pre-existing transition activities and team members
• Regular face-to-face meetings between pediatric and IM providers are
crucial to build the trust necessary to move the transition process forward
Table 1: Progress in HCT process implementation as measured by total
PMT scores (average scores reported as a % of total possible points)
Average
Score (%)
SD Effect
Size
P-valuea
Combined Average for Participating
Pediatric Divisions (n = 3)
Baseline (T1) 23% 3%
10 months (T2) 43% 10% 2.71 0.10
17 months (T3) 69% 10% 6.38 0.02
Combined Average for Participating
IM Divisions (n = 3)
Baseline (T1) 30% 26%
10 months (T2) 36% 12% 0.33 0.67
17 months (T3) 46% 23% 0.66 0.62
a
Calculated using repeated measures t test