We are team

Children’s Mercy Hospital is a regional pediatric hospital, and among the top 10 pediatric hospitals in the nation. With hundreds of subspecialty clinics, excellent care is available for practically every pediatric condition.

If we do our jobs right, our patients become adults, with as much functional independence as their physical and cognitive condition allows. More children with chronic disease are surviving into adulthood than ever. However, our patients are not prepared to enter the adult care world. Our hospital does not have a consistent program to transition our patients into adult care.

However, the future health and well-being of our patients depends not only on how well we take care of them while they are children, but on how well we prepare them for the adult health care world. This launching phase into adult care is complex, and potential barriers are numerous.

Transition represents our final obligation to our patients.

Our project encompasses the strategic development of the process of transitions for patients with childhood onset, chronic diseases. Carefully launched, our patients will stay healthy, and receive consistent care, which ultimately lowers cumulative health care costs.

Imagine instead that all teens and young adults with chronic disease or disability have a consistent transition process.

Care that is uninterrupted, seamless and coordinated health care results in better outcomes, and may be less costly, than care that is fragmented

The transition methods and tools will be sustainable, with measurable outcome metrics, including patient, parent and provider satisfaction,

When care is not seamless, a“Gap” of care results. The literature shows that the "Gap" results in delays of care, and health crisis management, rather than preventative care.
By avoiding the gap, complications and costs will decrease.

Transitions represent the final, and crucial, obligation of pediatric providers on behalf of our patients.

We recognize the barriers, and we see that they can be overcome by creative and strategic innovation.

This strategy canvas shows the current view, with the red line, and the view of the future, as the green line.

Across the x axis are the variables including

aligned with Children's Mercy's vision,

few silos

patient focus

future focus

broad input---from stakeholders

including a teen and family voice

uniformity across all the specialties in the hospital

and timely

This slide looks at all of our Bets Placed>
The first, that change agents such as IT and social media will play an increasingly important role with transitions and can effect improvements in patient introductions and follow-ups. This results in enhanced communication.

The second, relative to policy, legislation and insurance companies, we must make it more attractive to transition, than to not transition

3. Industry wide, we must change the culture. We must place decisive action to make it the norm for the industry to embrace transitions. Our patients just get one chance We must get it right.

4. Whether we change our culture or not, we face increased competition. In a health care culture that values numbers of patients more than quality of patient encounters, the accountable care system will drive us to do transitions well.

Vision:
“We will be the national and international premier transition model through innovative and sustainable processes, platforms and automated procedures, resulting in measurable, improved clinical outcomes, greater care efficiencies, and cost savings, and stakeholder satisfaction”

WHY?
Specific transitions programming will complement and complete the greater CMH vision. It will strengthen our market share in age groups that are most appropriate for our mission, and provide a direct and earnest way of assuring that ongoing care is provided with equal diligence.

Our strategy statement is truly lofty. We want to transform how care is given. This will impact all chronic patients who become adults under our care.

By 2017, all patients over 21 will transition without a gap in care

We will link with community and regional providers to create pathways of care for our patients.

The value of this will be not only in its initial impact, but mores in its continuous improvement cycle.

This slide addresses the objectives, advantage and scope.

Really, these are the same concepts.
The objectives are that it is, well, objective.
We do things the same ways and measure success with a transparent dashboard, and insist upon accountability.

regarding advantage, we must remember that our customers are not only our patients, but also the pediatric and adult providers, and the payer source, or the 3 P's. What works for the patients works for the system.

The scope of this endeavor is broader than Children's Mercy. Initially, it just impacts young adults, but with ongoing successful transitions, the young adults become older, and this, indeed, becomes our community. Doing this transition now means that later, health care is better for all.

Mission:
“We improve the long-term health of patients with childhood onset chronic health conditions by creating a comprehensive, patient and family centered transitions process, and by building a matrix of adult-based care providers locally and regionally. By encorporating education, training, tools, and research on outcomes, we will transform the process of transitions, assuring sustainable clinical and service excellence through and beyond our clinical ages of service”.
WHY?
This assures that our patients leave our institution with purposeful attention to their long-term needs. Done poorly, the downstream implications include corrosion of our reputation, a sense of abandonment, and potentially, a loss of future philanthropic support. In contrast, by excelling at this phase, we strategically create a bond with our patients, their parents, and their pediatric and adult providers that will be solid and lasting.

Here are our strategic initiatives.Whys:
1. Building Transitions as a system just for today, or just for this project, will not impact care significantly. Instead we can count up the lost opportunities and costs if this endeavor fails to launch. The process must be built with the idea that what we create today will best serve the generations that follow. Transitions can and should become the last, and perhaps the most important, obligation we have to our pediatric patients.
2. Alliances that are formed may be crucial to the ongoing success of the enterprise. With the increasing complexity of medical care, siding with a particular provider may ultimately be detrimental to the hospital as a whole. As contracts for health care are built, it may be that adult-based care is formulated after the same pediatric and transition constructs that we strive to promote. If this is the case, the decision to reach out to community providers should be based first upon expertise, but next, upon strategy, to meet objects for the hospital’s mission.
3. Networks of care will assure that a challenging patient, or patient population, each has an equally good chance of being transitioned to a quality, skilled provider, as does the well-insured and logistically, easier patient.
A “tit-for-tat” business model will assist with scalability, as in Andrew Zolli’s models f

Successful transition requires:
- deliberate and diligent planning,
- ongoing assessment of best practices,
- purposeful communication,
- policy and tool development
- and full electronic integration.

But what does the Transition Plan like?

Patients often ask" How do I know if I am ready to leave." and providers ask "How do I know my patient will succeed in the adult world.

This transition plan is attempts to break down what might be the biggest barrier to success: lack of confidence.

It is important to remember that all the patients at Children's Mercy are kids. And if being a teenager, wasn't hard enough, they have to navigate the complex healthcare industry in ways many of us never have.

The earliest elements of this transition plan are basic:

1) Patients are reminded during clinical visits that they will be leaving. This is not a conversation that happens on their 21st birthday, but one that starts at age 12 and is discussed frequently and frankly.

2) Patients will have solo interactions with the providers. They will learn how to be comfortable representing their own health needs.

3) Patients will be coached on a "Three sentence Health Summary." Because teens can feel intimidated by medical providers, learning how to communicate the essence of their needs under the counsel of a knowing provider is important.

It will give the teen the a message that they are knowledgeable about their health and can focus the doctor's attention on what is important.

To make Transition a universal practice in Children's Mercy, all providers with all patients during all visits will follow the: SHARED MANAGEMENT MODEL

SMM deliberately creates therapeutic alliances between patient/family and providers to work together, to help the patient accumulate the skills they will need in the future.

The model shifts responsibility for care gradually, as you see from the graph.

Patient increases participation in health care decisions and management in an age-appropriate & developmentally appropriate manner.

Ex: 3 yo who takes insulin walks to the refrigerator and get insulin to give to parent to administer. When ready, the patient will learn how to administer their own insulin with coaching.

The ultimate goal is that the health-care team and parent move into consultant roles and the teen becomes the supervisor of their own health.

While Patient-as-the-Executive is the goal, it is not realistic for everyone.

Not all patients will reach independence, and transition emphasis must shift appropriately.

Patients are launched on one of three tracks, based off the expectation for future care:

Each of these tracks:

- Independence
- Partial Independence
- Ongoing Dependence

Has defined goals and processes.

Each track has unique tools to promote training and communication.

Earlier we met Alan. He's part of the "I cans"-- youth who are expected to become independent healthcare decision makers as adults.

Transitioning this group means directly providing them guidance, training regarding their own care, goal setting and resources.

Partial Independence comprises the "I am willing" group, the group to which Emily belongs.

This group needs more intensive training and coaching to reach independence.

They may need ongoing adult assistance or guidance for saftey and success.

They are the target for most of the transitions interventions, which we will discuss shortly.

Transitioning the "I am willings" will involve coaching, and goal setting for both them and their guardian.

Marco's ongoing dependence on his caregiving places him in the "I can't's" group. On this track, patients are expected, due to the complexity of needs, to remain dependent on others for their adult based care.

Transition efforts here are geared towards caregiver training.

While these tracks have distinct courses, one important component integrating all three is the:
ELECTRONIC MEDICAL RECORD.

Not just elemental as a medical history, the patients EMR's will also alert every provider of the transitioning track the patient is following.

Green for I Can
Yellow for I'm willing
Red for I Cannot

Integrating the transitioning process with the EMR reminds physicians of the importance of preparing their patient for the future. It also harmonizes the many different providers around a shared objective.

Upon completion of the transition, the EMR is flagged "Patient Transitioned." The history of the transition is attached, and provides helpful details to the receiving provider or institution.

So what is in that attachment?

The meat of the entire process:
The transition action plan.

Providers develop personalized plans that map out the entire transition. This plan is than introduced to the patient and guardian in three phases: Investigating, Coaching, Launching

- Each phase has its own corresponding Readiness Checklist.

- These checklists have specific goals for the patient/parent and provider, with outlined strategies and focused teaching included.

- starting at age 12, These checklists pop up on the EMR each visit, prompting the provider to asses progress. Again, a reminder that transitioning is an ongoing process.

And once again, color coding informs the provider of the patients progress: red for not yet attempted, yellow for in process and green for mastery.

When mastery is demonstrated, the phase is complete and the next phase begins.

This accomplishment is noted on the patient's EMR, but it is also stamped in a booklet the patient keeps, called and resembling a passport.

The passport is the patients' personal record of their journey.

It brings the transition action plan to life for the patient, in a way a green flag on an EMR cannot. As the stamps accumulate, the patient can see how far they've come and what they've got left to go.

The patient passport is also a community outreach tool for children's mercy. Local organizations can have the opportunity to be part of the process by offering rewards for stamps, or full passport pages. Movie tickets, an iced cream cone, or a round of miniature golf are small potatoes when being publicly associated with supporting sick children from the community.

The completion of the transition is a full passport. Clinics may develop rituals regarding this final step and community partners may provide more significant rewards (maybe tickets to a chiefs game since they have cut support to programs like children's classes at a museum to focus on children's health).

The last component of transitions are group sessions. These come in a variety of forms, such as:

Formal education classes
Practice Sessions
Camps
Group Seminars
Vocational rehabilitation and
Transition clinics with transition champions as teachers

Group learning provides additional training, coaching and guidance-- but most importantly, it brings people who are experiencing similar challenges together.

Individuals with strong support networks are healthier, more resilient and happier than those without.

Practice sessions, for example, are groups of like-ability patients brought together to learn new skills, while at the same time learning from eachother.

They also allow patients to form connections with people going through similar experiences.

With technology so ubiquitous, online forums can connect people across the globe, who are encountering the exact same affliction.

This slide looks at all of our Bets Placed>
The first, that change agents such as IT and social media will play an increasingly important role with transitions and can effect improvements in patient introductions and follow-ups. This results in enhanced communication.

The second, relative to policy, legislation and insurance companies, we must make it more attractive to transition, than to not transition

3. Industry wide, we must change the culture. We must place decisive action to make it the norm for the industry to embrace transitions. Our patients just get one chance We must get it right.

4. Whether we change our culture or not, we face increased competition. In a health care culture that values numbers of patients more than quality of patient encounters, the accountable care system will drive us to do transitions well.