1. Medical Education in Transition Medicine Sarah Mennito, MD MSCR Assistant Professor, Departments of Pediatrics and Internal Medicine Program Director, Internal Medicine/Pediatrics Residency Medical University of South Carolina Charleston, SC mennito@musc.edu

2. Disclosures The speaker has no financial or commercial relationships to disclose related to this material

3. Objectives Describe the “problem” of transition and barriers to providing appropriate services reported by providers Understand efforts at transitional care training in graduate and undergraduate medical education Discuss future directions for local transition education initiatives

4. Scope of the Issue 20.9% of children in South Carolina are children with special health care needs age 12- 17 years – 90% expected to survive into adulthood – Only 41% receive adequate transition services National Survey of Children with Special Health Care Needs 2009-2010. Data Resource Center for Child and Adolescent Health http://cshcndata.org.http://cshcndata.org.

5. Barriers Pediatricians Communicating with adult provider Perception of resistance to transition by patients/families Reluctance to “give up” the patient Internists Lack of training – congenital and childhood-onset illness, adolescent medicine, developmental/behavioral medicine Caring for patients with severe intellectual disability if family does not stay involved Meeting psychosocial needs of a young adult with chronic illness Scal, P. Transition for Youth With Chronic Conditions: Primary Care Physicians’ Approaches. Pediatrics 2002; 110: 1315-1321. Reiss JG, Gibson RW, Walker LR. Health Care Transition: Youth, Family, and Provider Perspectives. Pediatrics 2005; 115: 112-120. Peter NG et al. Transition from pediatric to adult care: internists’ perspectives. Pediatrics 2009;123:417-423.

6. Need for Training Statements on Transition – 2002: “Identify…core knowledge and skills required to provide…health care transition services to young people with special health care needs and make them part of training and certification requirements for primary care residents and physicians in practice” – 2011: “Promotion of training and clinical learning experience on transition and transfer of youth and young adults (both with and without special needs) for trainees in all medical fields” AAP, AAFP, ACP-ASIM. A consensus statement on health care transition for young adults with special health care needs. Pediatrics 2002; 110:1304-1306. AAP, AAFP, ACP Transitions Clinical Report Authoring Group. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics 2011; 128:182-200.

7. South Carolina Resident Survey Assess preferences of residents in primary care training programs in South Carolina for format, timing, and content of a transition medicine curriculum 11 programs in 3 institutions – Internal Medicine, Pediatrics, Med/Peds, FM – MUSC, USC, Greenville

8. Results Majority of resident report monthly interactions with patients of immediate transition age (age 16-24y) All topics on average ranked moderate-high need/interest 79% of residents prefer clinical experience for education in transition Nearly 80% of pediatric residents and 50% internal medicine residents would find value in seeing patients older/younger than dictated by training Mennito S. Resident Preferences for A Curriculum in Health Care Transitions for Young Adults. Southern Medical Journal 105(9): 462-466.

9. National Educational Initiatives: UME Undergraduate – 1 week course for medical students at UAB – Emphasizes patient and family-centered care, cultural competence and decision-making in end-of-life issues – Uses cystic fibrosis as model Hagood JS, Lenker CV, Thrasher S. A Course on the Transition to Adult Care of Patients with Childhood-Onset Chronic Disease. Academic Medicine 80 (4): 352-355.

10. National Educational Initiatives: GME Indiana – Resident and medical student 1 month rotation Center for Youth and Adults with Conditions of Childhood (CYACC) and subspecialty clinics Harvard – “Cross Over Curriculum” Univ of South Florida – Use of EHR transition tool to teach/encourage transition discussion Brown – Multidisciplinary rotation Experience with community resource providers (schools, DoH, legal) and advocates for families and people with disabilities

11. MUSC Transitions Elective Rotating resident elective through various adult and pediatric specialty clinics providing transitional care Weekly meetings with oversight faculty Performance of small project with results returned to participating clinics **Currently only Med/Peds residents**

12. MUSC Educational Initiatives Med/Peds Morning Report – 6 times/year on medicine and pediatrics Case presented by MP resident – Topics related to crossover disease or transition Med/Peds Noon Conference 5 conferences/year Presented to IM, Peds and MP residents by MP resident or MP PD

13. Future Directions Resident Primary Care Clinics – Transition policies – University Internal Medicine “pipeline” Collaboration with Family Medicine Undergraduate curriculum Involvement of community resource providers in resident curriculum

14. Acknowledgments MUSC Transitions Working Group/Transition Task Force MUSC Med/Peds Residents Faculty and staff participants in the Transitions Elective

15. Questions?