Care Coordination and Comprehensive Electronic Health Records are Associated With Increased Transition Planning Activities

Sharma, Niraj; O’Hare, Kitty; O’Connor, Karen G.; Nehal, Umbereen S.; Okumura, Megumi J.

doi:10.1016/j.acap.2017.04.005

Cited by 25 publications

(21 citation statements)

References 21 publications

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“…134 Care coordination is a common feature associated with increased transition planning activities. 135 136 clinicians should incorporate oneon-one time with youth during the medical visit to better prepare youth for managing their own health and health care. One-on-one time has been shown to increase adherence to care, engagement in care, and the likelihood of sharing health risks with their clinician.…”

Section: Outcome Evidence For Pediatric To Adult Hct Interventionmentioning

confidence: 99%

“…159 In the ideal situation, the availability of care coordination support to guide the transition process and team-based care 160 in both the pediatric and adult settings increases chances of success. 135,161 Clinicians from nursing and social work professions often fill this important role and often drive the HCT QI process. 162 -164 Families also need assistance with their new role in the health care of their young adult.…”

Section: Figurementioning

confidence: 99%

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Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

2018

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Risk and vulnerability encompass many dimensions of the transition from adolescence to adulthood. Transition from pediatric, parent-supervised health care to more independent, patient-centered adult health care is no exception. The tenets and algorithm of the original 2011 clinical report, "Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home, " are unchanged. This updated clinical report provides more practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults. It also includes new and updated sections on definition and guiding principles, the status of health care transition preparation among youth, barriers, outcome evidence, recommended health care transition processes and implementation strategies using quality improvement methods, special populations, education and training in pediatric onset conditions, and payment options. The clinical report also includes new recommendations pertaining to infrastructure, education and training, payment, and research.

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Section: Outcome Evidence For Pediatric To Adult Hct Interventionmentioning

confidence: 99%

Section: Figurementioning

confidence: 99%

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

2018

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“…Receiving family-centered care, care coordination support, care in a medical home, and having a written plan were each positively associated with 2 of the 3 elements (active work to gain skills or understand changes in health at 18 and time alone with an HCP). 47 or between ages 18 and 20. 48 For YSHCN, the finding that care coordination was significantly associated with overall transition performance is also not unexpected.…”

Section: Resultsmentioning

confidence: 99%

“…Researchers have shown that care coordination is associated with improved transition procedures, and when pediatric practices have a designated individual responsible for care coordination, they are more likely to have a written transition plan. 47 Current measures of transition planning may not adequately predict youth engagement in care or successful transfer to adult care. 49 With our study, we found that non-Hispanic black or African American youth were more likely to work with their HCP to gain skills and understand changes at 18, compared with non-Hispanic white youth but were also less likely to discuss the shift to an adult HCP.…”

Section: Resultsmentioning

confidence: 99%

Transition Planning Among US Youth With and Without Special Health Care Needs

et al. 2018

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“… 21 In addition to the medical summary, having a formal, written transition plan is considered a best practice, 37 and using the electronic health record system is thought to facilitate this task. 104 …”

Section: Transferring the Patient: Best Practices For Paediatric And mentioning

confidence: 99%

Transition and transfer of the patient with paediatric-onset lupus: a practical approach for paediatric and adult rheumatology practices

Sadun

Schanberg

2018

Lupus Sci Med

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The prevalence of paediatric-onset SLE (pSLE) is estimated at 1million people worldwide and accounts for a significant proportion of SLE morbidity, mortality and cost. Patients with pSLE are especially vulnerable during and immediately following transfer from paediatric to adult rheumatology care, when substantial delays in care and increased disease activity are common. Transition is the process through which adolescents and young adults (AYA) develop the skills needed to succeed in the adult healthcare environment, a process that typically takes several years and may span a patient’s time in paediatric and adult clinics. Recommendations for improving transition and transfer for AYA with pSLE include setting expectations of the AYA patient and family concerning transition and transfer, developing AYA’s self-management skills, preparing an individualised transition plan that identifies a date for transfer, transferring at a time of medical and social stability, coordinating communication between the paediatric and adult rheumatologists (inclusive of both a medical summary and key social factors), and identifying a transition coordinator as a point person for care transfer and to monitor the AYA’s arrival and retention in adult rheumatology care. Of paramount importance is empowering the adult rheumatologist with skills that enhance rapport with AYA patients, engage AYA patients and families in adult care models, promote adherence and encourage ongoing development of self-management skills.

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Care Coordination and Comprehensive Electronic Health Records are Associated With Increased Transition Planning Activities

Cited by 25 publications

References 21 publications

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

Transition Planning Among US Youth With and Without Special Health Care Needs

Transition and transfer of the patient with paediatric-onset lupus: a practical approach for paediatric and adult rheumatology practices

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