1. Transition Care Pearls Alice Kuo, MD, PhD Med-Peds Rounds 12 January 2011

2. Recall Our Model Transition Preparation 4 components: Transition Preparation 4 components: Adult providers (including primary care) Adult providers (including primary care) Insurance status Insurance status Self-care skills Self-care skills Education/employment Education/employment

3. Another Way to Think About It Education/employment Insurance status Access to adult health providers Self-care skills Successful Transition!!

4. Self-care skills Education/employment Insurance status Access to adult health providers Self-care skills Successful Transition!! How much responsibility can the patient take for his/her care? What is this patient’s trajectory to independence? What will it take to maximize the trajectory?

5. Education/employment Education/employment Insurance status Access to adult health providers Self-care skills Successful Transition!! What is this patient’s educational attainment goal? Trade school, junior college or 4-year university? Government jobs come with good benefits Big companies often have better benefits than smaller ones

6. Insurance status Education/employment Insurance status Access to adult health providers Self-care skills Successful Transition!! Ways for adults to have health insurance: Parents’ insurance (until 26) Medicaid or Medicare Student health Employer-sponsored [Self-purchased commercial insurance] [Military/veterans]

7. Access to Health Providers Education/employment Insurance status Access to adult health providers Self-care skills Successful Transition!! UCLA vs. closer to home Don’t forget about primary care Mental health is tough Specialists depend on insurance and access

8. Patient-MD Match Although many patients eligible to be seen at VFC, many not willing to go to a free clinic Although many patients eligible to be seen at VFC, many not willing to go to a free clinic SMIMP: Medi-Cal able to be seen in resident clinics—schedule with one of the interns SMIMP: Medi-Cal able to be seen in resident clinics—schedule with one of the interns Your assessment of self-care skills should include evaluation of how much pt and/or family can do for themselves (don’t have to provide case management for every patient) Your assessment of self-care skills should include evaluation of how much pt and/or family can do for themselves (don’t have to provide case management for every patient)

9. How Much Primary Care Should We Provide? Depends on how much of a bridge we are Depends on how much of a bridge we are If pt has no PMD and has not yet connected with someone, we should refill meds If pt has no PMD and has not yet connected with someone, we should refill meds Connecting with mental health is role of PMD, despite impact of mental health on self-care skills Connecting with mental health is role of PMD, despite impact of mental health on self-care skills We are a consultative TCP model, not primary care model We are a consultative TCP model, not primary care model If extensive primary care is needed, refer to ourselves at Simms or SMIMP If extensive primary care is needed, refer to ourselves at Simms or SMIMP

10. Case #1 20 yo with SLE stable on three meds 20 yo with SLE stable on three meds Sophomore at Azusa Pacific University Sophomore at Azusa Pacific University

11. Case #1 20 yo with SLE stable on three meds 20 yo with SLE stable on three meds Sophomore at Azusa Pacific University Sophomore at Azusa Pacific University Self-care skills, education, and insurance status all taken care of Preferred doctors closer to school Mom had internist who would be her PMD Either call insurance card for rheumatologist or ask PMD to refer to someone Talked about grad school— increase likelihood of getting job with benefits

12. Case #2 25 yo with mental retardation, chromosome 18 deletion, seizure disorder 25 yo with mental retardation, chromosome 18 deletion, seizure disorder Osteopenia on DEXA, on Vit D Osteopenia on DEXA, on Vit D Has straight Medi-Cal Has straight Medi-Cal Dad works at a bakery, is 60 yo Dad works at a bakery, is 60 yo

13. Case #2 25 yo with mental retardation, chromosome 18 deletion, seizure disorder 25 yo with mental retardation, chromosome 18 deletion, seizure disorder Osteopenia on DEXA, on Vit D Osteopenia on DEXA, on Vit D Has straight Medi-Cal Has straight Medi-Cal Dad works at a bakery, is 60 yo Dad works at a bakery, is 60 yo Primary care: Simms vs. SMIMP Neurology: county vs. UCLA fellows Recommend adult- appropriate Vit D dose + calcium When Dad turns 65 and gets Medicare, pt may be able to apply for dependent benefits

14. Case #3 STAT consult STAT consult 21 yo Turner’s syndrome on her birthday; would lose CCS next day 21 yo Turner’s syndrome on her birthday; would lose CCS next day Undocumented Undocumented Parents are migrant farm workers in Bakersfield Parents are migrant farm workers in Bakersfield

15. Case #3 STAT consult STAT consult 21 yo Turner’s syndrome on her birthday; would lose CCS next day 21 yo Turner’s syndrome on her birthday; would lose CCS next day Undocumented Undocumented Sophomore in community college Sophomore in community college Parents are migrant farm workers in Bakersfield Parents are migrant farm workers in Bakersfield Encourage pt to try to get job with benefits Safety net system Community clinic for primary care, meds County medical center for specialty care Had been seeing peds endo since age 14; no one talked with her about infertility

16. Case #4 (trainwreck) 20 yo with sickle cell and asthma 20 yo with sickle cell and asthma Multiple ER visits for pain crises Multiple ER visits for pain crises Complicated social situation [discuss] Complicated social situation [discuss]

17. Case #4 (trainwreck) 20 yo with sickle cell and asthma 20 yo with sickle cell and asthma Multiple ER visits for pain crises Multiple ER visits for pain crises Complicated social situation [discuss] Complicated social situation [discuss] Tried to identify PMD and hematologist in SF Valley Had to help pt switch from Medi-Cal HMO to straight Medi-Cal After 1 yr, pt decides to keep MDs at UCLA Pt self-motivated to go to school and to get job

18. Overall Approach in TCP Clinic Review chart on arrival Review chart on arrival Go over two forms with patient—self-care skills rating and patient questionnaire Go over two forms with patient—self-care skills rating and patient questionnaire Present to attending Present to attending Come up with plan, focused on four components of the TCP model Come up with plan, focused on four components of the TCP model DICTATE your note; any TCP clinic note should be able to serve as handoff note to a new PMD; remember to cc referring physician DICTATE your note; any TCP clinic note should be able to serve as handoff note to a new PMD; remember to cc referring physician Goal of entire encounter should be 45-60 minutes Goal of entire encounter should be 45-60 minutes

19. Ways to Save Time Patient questionnaire provides most if not all information for template of TCP note Patient questionnaire provides most if not all information for template of TCP note Focus on connecting pt with a PMD Focus on connecting pt with a PMD Don’t need to look for individual specialists all over L.A. county or beyond Don’t need to look for individual specialists all over L.A. county or beyond Pt needs to take responsibility for care as well Pt needs to take responsibility for care as well Bring back for return visits if necessary; discharge from clinic if possible Bring back for return visits if necessary; discharge from clinic if possible

20. TCP and Med-Peds Hot topic this year on interview trail Hot topic this year on interview trail Specialization within med-peds Specialization within med-peds Ability to bill as specialists Ability to bill as specialists Next steps: Next steps: Need to work with pediatric specialists Need to work with pediatric specialists More education for pediatrics to do better transition preparation themselves More education for pediatrics to do better transition preparation themselves More education for internists to receive these patients More education for internists to receive these patients

21. Questions? Discussion?