Paving the Rocky Road Definitions for Young Adults: Guidelines - - PowerPoint PPT Presentation

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Paving the Rocky Road Definitions for Young Adults: Guidelines - - PowerPoint PPT Presentation

Dec 31, 2023 150 likes •283 views

9/30/2016 Transitioning the adolescent with kidney disease Paving the Rocky Road Definitions for Young Adults: Guidelines A Unique Model of Care Current understanding of transition Transitional planning Policy and

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Paving the Rocky Road for Young Adults: A Unique Model of Care

Elaine Ku, MD Assistant Professor University of California, San Francisco Departments of Medicine and Pediatrics Division of Nephrology and Pediatric Nephrology

Transitioning the adolescent with kidney disease

  • Definitions
  • Guidelines
  • Current understanding of transition
  • Transitional planning
  • Policy and insurance issues

Outline

  • Definitions
  • Guidelines
  • Current understanding of transition
  • Transitional planning
  • Policy issues

Definition – the transitional process

  • Transition

▫ “a purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult

  • riented health-care systems”
  • Transfer

▫ “the act of moving from one provider to another or from one location to another”

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Outline

  • Definitions
  • Guidelines
  • Current understanding of transition
  • Transitional planning
  • Policy issues

IPNA guidelines

  • Transfer should be

▫ Individualized for each patient after completion of transition plan (based on educational, social, and psychological attainment) ▫ Agreed jointly by patient and his/her family and pediatric and adult renal care teams ▫ Take place during a period without crises ▫ Take place after completing school education ▫ Take into account treatment plans by other subspecialties, especially with reference to urological supervision ▫ Take place with due consideration of financial factors

Gottransition.org

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Transition checklist IPNA guidelines

  • Most effective time to transfer is after transition

process

▫ Introduce concept of transition during early adolescence (12-14 years) ▫ Give information about transition in a gradual manner ▫ Directed by lead clinicians (“transition champions) ▫ Assigned to a nominated key worker responsible for coordinating transition ▫ Have an individualized transition plan ▫ Be offered informal visit to adult clinics

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IPNA guidelines IPNA guidelines

  • Transition or transfer clinic

▫ should include adult and pediatric nephrologists in attendance optimally ▫ Internal medicine specialist or nephrologist should take special interest and be trained in managing young people with advanced CKD ▫ Include comprehensive written and verbal summary of all aspects of young person’s care ▫ Young person should be prepared though a transition pathway to assert their autonomy

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Outline

  • Definitions
  • Guidelines
  • Current understanding of transition
  • Transitional planning
  • Policy issues

Adolescent views on transition in diabetes and nephrology

  • Tong A, Eur J Ped, 2013
  • Tong A, Eur J Ped, 2013
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Ped Nephrology April 2014

Adherence to IPNA guidelines Models of transition

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Models of transition

P = 0.002

Adherence and lack thereof

  • Average non-compliance rate is 32% in pooled studies
  • 43.2% if limited to adolescents
  • Accounts for 14 % of graft loss and 23% late acute

rejection episodes

Outline

  • Definitions
  • Guidelines

▫ General pediatrics ▫ Nephrology

  • Current understanding of transition

▫ In general pediatric patient ▫ In nephrology patient

  • Transitional planning
  • Policy issues

Core elements of transition

Cooley W, 2014, JAMA Pediatrics

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Core elements of transition

Cooley W, 2014, JAMA Pediatrics

Transition registry Transition registry Core elements of transition

Cooley W, 2014, JAMA Pediatrics

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Transition Team

  • Elaine Ku, MD

Adult and Pediatric Nephrology Director, Transition Clinic

  • Deborah Adey, MD

Adult Kidney Transplant

  • Marissa Fleisch-Raymond, MD

Adolescent Medicine

  • Anthony Portale, MD

Pediatric Kidney Transplant

  • Lisa Keung, RD

Pediatric Renal Dietician

  • Danielle Krieger, NP

Adult Kidney Transplant

  • Jessica Brennan, NP

Pediatric Kidney Transplant

  • Holly Synder, NP

Adult Kidney Transplant

  • Marilyn McEnhill, NP

Pediatric Kidney Transplant

  • Elizabeth Wayne, NP

Adult Kidney Transplant

  • Taryn Shappell, LCWS

Pediatric Social Worker

  • Amanda Watts, MSW

Adult Social Worker

  • Sarah Baky, MSW

Adult Social Worker

Division of Responsibilities

Age of patient Transition Clinic (based at BCH Mission Bay) Adult Kidney Transplant Clinic (or adult local nephrologist if KTU clinic

  • nly needed once a year)

Lab follow-up 21 3 times a year 1 time a year Pediatric team 22 2 times a year 2 times a year Pediatric team 23 1 time a year 3 times a year Pediatric team 24 Pediatric team is available to support patient if needed Assumes full responsibility Adult team

Core elements of transition

Cooley W, 2014, JAMA Pediatrics

Transition Planning

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Medical health passport

  • https://www.sickkids.ca/myhealthpassport/

Medical health passport Core elements of transition

Cooley W, 2014, JAMA Pediatrics

Outline

  • Definitions
  • Guidelines

▫ General pediatrics ▫ Nephrology

  • Current understanding of transition

▫ In general pediatric patient ▫ In nephrology patient

  • Transitional planning
  • Policy issues, billing, and resources
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Insurance coverage Insurance options for young adults

  • Staying on your parent’s plan until you are 26 years
  • ld
  • Medicaid coverage, depending on your income level

and state

  • Job-based insurance coverage, if your employer

provides it to you

  • Student health insurance, depending on your school
  • Purchasing your own plan
  • Resources

▫ http://health.younginvincibles.org/consumers-2/ ▫ http://health.usnews.com/health-news/health- plans/articles/2011/01/13/best-affordable-health- insurance-options-for-young-adults

Policy issues

  • Affordable Care Act

▫ Improved access of young adults to health care insurance through Medicaid expansion in some states and the extension of dependent eligibility to age 26 years in private insurance plans ▫ elimination of lifetime caps on insurance benefits and preexisting conditions as obstacles to coverage

  • Provider payment reform are needed to incentivize both

pediatric and adult providers to deliver high-quality transition care

  • Many transition services and supports such as patient

education and care coordination fall outside of the usual encounter and procedure-based fee for service coding systems

  • The transition process may extend over a period in which both

pediatric and adult providers should be involved, requiring a mechanism for payment to bridge care

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Billing

  • CPT 99214 and 99215 for prolonged visits with > 50%

visit spent on counseling

  • CPT codes 99374 (15–29 minutes) and 99375 ( >30

minutes) for “care plan oversight” - activity outside of

  • ffice encounters involved in the management of a

youth’s transition plan (whether it stands alone or is incorporated into a more general care plan for a chronic condition) constitutes “care plan oversight.”

▫ Phone calls to prospective adult primary care physicians or medical subspecialists ▫ conversations with the youth and family regarding transition plans, or communication with community agencies integral to the transition process