Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging...

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Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Disease

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Transcript of Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging...

Page 1: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Rachel Bensen, MD, MPHDana Steidtmann, PhD

Yana Vaks, MD

Mentor: Arnold Milstein, MD, MPH

Bridging The Gap:Transition from Pediatric to Adult Care for Young Adults

With Childhood Onset Chronic Disease

Page 2: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

The Triple Aim

Improving patient experience

Lowering per capita costsImproving

population outcomes

Page 3: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

“Boot Camp”

Literature Review

Observations, Needs Assessment, Expert Consultation

Prototyping

Model Refinement

Identification of pilot sites

Implementation

Evaluation & Further Refinement

Dissemination of Successful Models

Year 1

Year 2

Beyond

http://cerc.stanford.edu

Page 4: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

“I feel like I am a burden to everyone”

“Transition is so serious and so scary”

“When is it going to be my turn to talk?”

“Patients want a life program,not a medical program”

“There is no quarterback”“This is a patient safety issue”

Page 5: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Consensus Statement on Transitions(2002, 2011)

Purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of young people with chronic medical conditions, as they move from child-centered to adult-oriented health care system

Page 6: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Pediatrics Specialized Adult Medical Home

Pediatrics Transition Clinic Adult Care

Remain within the Pediatric System

Transition Processes Now

Pediatrics +/- Transition Preparation or Consult

Adult Care

Page 7: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Spikes in Health Crises

Brousseau et al 2010 (JAMA) Acute Care Utilization and Rehospitalizations for Sickle Cell Disease

Page 8: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Disease -

Who are we talking about?

Age: 15-25 years

US: 39.2 million

5-10% (4 million) have serious chronic conditions

0.5 million young adults transition from pediatric to adult care every year

2010 US Census Data

Cerebral palsyType I DiabetesCystic FibrosisCongenital heart diseaseTransplantsRare genetic and metabolic disordersSevere asthma Spina bifidaInflammatory bowel disease LupusSickle Cell DiseaseMuscular Dystrophyand many others…

Page 9: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

ConnorAge: 19

Muscular Dystrophy

DianaAge: 22

Cerebral Palsy

GabeAge: 17

Type I Diabetes

= Costly, avoidable hospitalizations & unnecessary suffering

Page 10: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Bridging The Gap:Transition from Pediatric to Adult Care

For Young Adults with Childhood Onset Chronic Disease

Build and support self-management skills

Team-up providers to match care to changing patient needs

Guide patients & families through service changes to avoid care laps

~15% net reduction in annual per capita medical spending for target population

Build and support self-management skills

Guide patients & families through service changes

Tele-mediated specialty support

Page 11: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Ongoing Assessment

Dial services up and downMatch individual needs

Real time remote check-insPrompt responsesAvoid acute crises

Psychosocial

Mental Health

Page 12: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Health Coach1.5 FTE*

Navigator4 FTEs*

Bridge Team• Lead & oversee the Bridge Team• Organize medical care most medically fragile• Provide medical back up• Quality control

• 1-to-1 coaching to motivate and build skills for self management of illness

• Orient to device based self tracking tools• Support during high risk periods• Mentorship

• Point-of-contact during transition• Assess risk factors to match to relevant resources• Transition readiness checklist• Outreach during high risk periods• Educate on what to expect during transition• Mentorship

*Per 300patients

Page 13: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Difficult Period• Medical issues exacerbated

• Being a teenager is tough• Mental health problems surface• Caregiver fatigue Decreased treatment adherence

Mismatched Care• Limited care coordination • Gaps in knowledge & support• Not suited to busy patient lifestyles

Avoidable hospitalization and increased ER use

The Gap• Complex systems are hard to maneuver

• Fear of the unknown• Service changes• Lack of system interoperability

Lapses in care and unnecessary tests

Cha

lleng

esBridging The Gap

Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Illness

Build & Support Self-Management

• Technology-supported: • Health coaching• Treatment for anxiety &

depression• Peer support

Guide Patients & Families

• Navigation services• Transition checklist• Personal Health Record• Link to local resources

• Pull system to ensure stable arrival

Tele-mediated specialty and care coordination support

• Enhance care coordination• Support primary care • Improve access

The Patient

S

oluti

ons

Predicted Gains: Clinical Outcomes Patient & Family Experience Spending 15%

BRIDGE TEAM: Advanced Practice Providers, Navigators, Health Coaches

ONGOING ASSESSMENT Patient segmentation to dial care level up and down

The System The Handoff

Page 14: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Difficult Period• Medical issues exacerbated

• Being a teenager is tough• Mental health problems surface• Caregiver fatigue Decreased treatment adherence

Mismatched Care• Limited care coordination capability• Gaps in knowledge & support• Not suited to busy patient lifestyles

Avoidable hospitalization and increased ER use

The Gap• Complex systems are hard to maneuver

• Fear of the unknown• Service changes• Lack of system interoperability

Lapses in care and unnecessary tests

Cha

lleng

esBridging The Gap

Transition from Pediatric to Adult Care for Young Adults With Childhood Onset Chronic Illness

Build & Support Self-Management

• Technology-supported: • Health coaching• Treatment for anxiety &

depression• Peer support

Guide Patients & Families

• Navigation services• Transition checklist• Personal Health Record• Link to local resources

• Pull system to ensure stable arrival

Tele-mediated specialty and care coordination support

• Enhance care coordination• Support primary care • Improve access

S

oluti

ons

Predicted Gains: Clinical Outcomes Patient & Family Experience Spending 15%

BRIDGE TEAM: Advanced Practice Providers, Navigators, Health Coaches

ONGOING ASSESSMENT Patient segmentation to dial care level up and down

The Patient The System The Handoff

Page 15: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

ConnorAge: 19

Muscular Dystrophy

DianaAge: 22

Cerebral Palsy

GabeAge: 17

Type I Diabetes

• Remote specialist consults

• Online depression treatment for mother

• Health coach

• Navigator • Navigator • Navigator• Personal Health Record • Personal Health Record

• Remote specialist consults

• Personal Health Record

• Care coordination

• Flexible appointments

• Peer support

• Ongoing mental health screening

Page 16: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

Bridging The Gap

Page 17: Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH Bridging The Gap: Transition from Pediatric to Adult Care for.

We welcome your thoughts!

Yana [email protected]

Rachel [email protected]

mailto:[email protected]
mailto:[email protected]

Dr MargiAnne Isaia, MD MPH

Dr MargiAnne Isaia, MD MPH

Rachel Bensen, MD, MPH Dana Steidtmann, PhD Yana Vaks, MD Mentor: Arnold Milstein, MD, MPH

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