(240) Embracing change: Transforming transition for better outcomes

Background: Cystic fibrosis (CF) care teams have recognized the need for transition of care programs to prepare young people with CF (PwCF) for independent futures. Structured transition practices among CF programs are positively correlated with PwCF satisfaction, perceived health status, independence, and reduced medical complications. [1,2] In 2019, the UVA Children’s CF program reviewed informal transition processes with a goal of standardized a framework to be tested and adapted through iterative cycles to meet the needs and expectations of its young adult cohort. Tools and processes adopted into practice included team assessment of CF education and self-care skills; meeting between PwCF and an adult provider, self-assessments of readiness before and after interventions, and a system of measures to gauge the success of the program and drive decisions.

Methods: The team consisted of diverse stakeholders including the PNP, RN program coordinator, LCSW, PharmD, and patient family partner from the pediatric team; and the PsyD and QI lead affiliated with both adult and pediatric teams. A literature and resource review came first to adapt or develop tools aligned with the scope of practice and context of the organization. Educational and self-care goals by age were identified and built into a transition flowsheet in the EMR. A self-assessment tool for readiness was adopted to communicate expectations and aid goal setting at the beginning of the final year of pediatric care and again in the visit before transfer as a measure of patient confidence and intervention success. A process for PwCF to meet their adult provider prior to transfer was integrated. A transition cohort was reviewed monthly and when the transfer window was identified, tasks were planned for the final four pediatric visits. Process and outcome measures were identified and baseline data was gathered for pre and post transfer.

Results: The EMR flowsheet went live in November 2021 to capture transition skills starting at the age of three. At this time, 38 out of 116 (33%) PwCF aged 3 and above had transition flowsheet initiation. Out of 20 PwCF identified as being in the transfer window between 2021 and 2022, 9 (45%) had at least one readiness self-assessment and 6 (30%) met with their adult care team before transfer. Health outcome data will lag interventions and will be compared to pre-intervention baselines.

Conclusions: The transition program interventions aim to improve the perceptions of health, self-care confidence, and independence for PwCF. The strengths of the program are the commitment of the project team to meetings and action items. The tools and framework for tracking use and documenting results are essential for sustainability and evaluation. Next steps include refinement of the EMR flowsheet and sharing with our adult CF and hospital teams. Ongoing QI will ensure process and health outcomes are optimized. This work is adaptable to other services both within and outside our institution to enhance health outcomes in years to come.

Acknowledgements:

References: [1] Baker AM, Riekert KA, Sawicki GS, Eakin MN. CF Rise: implementing a clinic-based transition program. Pediatr Allergy Immunol Pulmonol. 2015;28:250-4. https://doi.org/10.1089/ped.2015.0594 [2] Chaudhry SR, Keaton M, Nasr SZ. Evaluation of a cystic fibrosis transition program from pediatric to adult care. Pediatr Pulmonol. 2013;48(7):658-665. doi:10.1002/ppul.22647