P0638 - Creating a Transitions of Care Curriculum at a Federally Qualified Health Care Center- A QI project

Since 2002, the national organizations of the ACP (American College of Physicians), AAP (American Academy of Pediatrics) and the AAFP (American Academy of Family Practice) have joined together to author joint statements on the importance of successfully transitioning pediatric patients into adult care. Studies have shown that youth who do not have transitional support have more medical complications, increased ED visits, more medication non-compliance, and limited health and well being. Unfortunately, despite the data favoring good transitions, only 15% of youth with or without special needs receive transition planning and assistance. Our federally qualified health care site, North County Health Services (NCHS), currently does not have a transitions of care process. This quality improvement project strives to create a culturally sensitive, comprehensive curriculum to fit our low-income, low-resource patient population. In doing so, we hope to equip and empower our patients to become strong advocates for their own health for the rest of their lives.
In this first phase of our QI project, we focused on establishing a need for such a curriculum and then creating a proof of concept for a comprehensive curriculum at one clinic site. We collected a total of 60 patient surveys and 60 parent surveys and analyzed the results to find that our patient population severely lacked the knowledge and skills to competently manage their own healthcare independently in an adult primary care practice. Based on these results, we then created a two pronged intervention for education and empowerment. The first intervention was a comprehensive curriculum that assessed transition skills by age level and either flagged a patient for further 1:1 education or gave them age-appropriate resources. This curriculum is to be implemented at each well child check (WCC) physical exam starting at age 14. The second intervention is a group education session to teach the most confusing topics of the transition to both teenagers and parents.
Based on our results and initial proof of concept curriculum, the NCHS administrators agree that this is a necessary addition to our patient care offerings and, together, we are working on including this project in the yearly clinic budget. Additionally, we have been meeting with physicians, clinicians, and staff from other NCHS clinic sites to hold focus groups on the feasibility of bringing this project to their site. In parallel, we are working with the IT department to integrate these assessments into a new electronic medical record (EMR). The goal is to make transition readiness assessment a routine part of WCC and to help at-risk teenagers be able to transition into adult medical care smoothly.