Transition of Care

Question 1

What are some special care needs that youth may have? (4)

Answer 1

1. Complex care
2. Chronic conditions
3. Psychosocial risk
4. Significant caregiver involvement

Question 2

Describe how the role of the HCP changes for a pediatric patient early in life, with increasing age, with increasing age part 2, then as an adult (4)

Answer 2

1. Early = Major responsibility
2. Increasing age = Support
3. Increasing age = Consultant
4. Adult = Resource

Question 3

Describe how the role of the caregiver/family changes for a pediatric patient early in life, with increasing age, with increasing age part 2, then as an adult (4)

Answer 3

1. Early = provides care
2. Increasing age = manages
3. Increasing age = supervisor
4. Adult = consultant

Question 4

Describe how the role of the patient changes early in life, with increasing age, with increasing age part 2, then as an adult (4)

Answer 4

1. Early = receives care
2. Increasing age = participates
3. Increasing age = manages
4. Adult = supervisor/CEO

Question 5

What are some differences between pediatric care and adult care? (4 each)

Answer 5

Pediatric Care:
1. Caregiver involvement
2. Family-oriented
3. Interdisciplinary
4. Psychosocial function
Adult Care:
1. Independence
2. Managing medications
3. Self-advocacy
4. Informed decision making

Question 6

__-__% of North American youth live with a chronic health condition

Answer 6

15-18%

Question 7

Why does transition of care even matter? (4)

Answer 7

1. Poor health outcomes
   - Increase in diabetes related hospital admission 2 years post-transfer
2. Caregiver burden
   - Substitute decision maker
3. Mental health
   - Vulnerable to declining mental health
4. Disengagement
   - 1/2 Ontario youth had 12-month gap in care while transitioning to adult care
   - 1/2 youth in UK study disengaged from mental health and substance abuse care

Question 8

What are some (5) pediatric transition of care guidelines to be aware of?

Answer 8

1. Canadian Pediatric Society
2. SickKids
3. Ontario - 6 Quality Statements
4. British Colombia - Person Centered, Clinical, System Recommendations
5. Montreal - 18 Steps Until 18

Question 9

Describe what the Canadian Pediatric Society does? (6)

Answer 9

1. Ensure care is continuous, and meets needs of all involved
   (patients, family, HCP’s)
2. Prepare youth gradually, timing is individualized –
   flexible age cut-offs
3. Collaboration between pediatric and adult care providers
4. Establish ‘quality indicators’ of successful transition
5. Educational reforms for youth, families, as well as HCP’s
6. Appropriate program funding

Question 10

Explain what Ontario Health does (6)

Answer 10

1. Early identification and transition readiness
2. Information sharing and support
3. Transition plan
4. Coordination transition
5. Introduction to adult services
6. Transfer completion

Question 11

Go through the SickKids timeline from <10, 10-13, 14-16, and 17-18 years old as to how to prepare kids for transition to adulthood

Answer 11

1. Very Early (<10) = learn name of medications
2. Early (10-13) = medication administration & appointment scheduling
3. Middle (14-16) = drug coverages changes
4. Late (17-18) = consolidation of health information

Question 12

What are some barriers to transition? (6)

Answer 12

1. Difficulty navigating healthcare system
2. Shift from holistic, interdisciplinary care to fragmented care
3. Difficulty finding a primary care provider to coordinate care
4. Shift in responsibility
5. ‘Fear of unknown’ for patients and family
6. Financial barriers

Question 13

What are some barriers to transition, specifically from a pediatric perspective? (6)

Answer 13

1. Adult HCP lack of specialized knowledge
2. Difficult to establish new relationships
3. Feelings of abandonment, grieving
4. Adult HCP less inclined to ‘listen’ – need to seek emergency care
5. Reduced time for appointments
6. Adult HCP less personable

Question 14

What is a transition champion?

Answer 14

“A clinician who takes responsibility for facilitating and coordinating the health care providers (HCPs) involved in a young person’s care, including primary care, and ensuring effective communication throughout the process”

Question 15

What are transition readiness tools?

Answer 15

Validated self-assessment tools for adolescents with chronic disease to assess readiness to transition to adult care

Question 16

Name 2 transition readiness tools

Answer 16

1. TRANSITION-Q
   - 14-items, 3 responses (never → always)
   - I answer a doctor’s or nurse’s questions
   - I participate in making decision about my health
2. Am I ON TRAC
   - 25-item, 5 responses (strongly disagree → strongly agree)
   - My family supports me in managing my health
   - I take my medications on my own

Question 17

With transition outcomes there is a lack of generalizability, consensus how a successful transition is defined and measured and limitations of disease specific outcomes. What are 3 proposed evaluation tools/approaches?

Answer 17

1. Triple Aim Framework – Institute for Health Care Improvement
   - Patient experience of care, Population health, Cost
2. International Classification of Function – World Health Organization
   - Psychosocial outcomes
3. Quality of Life Outcomes
   - Need for systematic processes to evaluate

Question 18

According to a UK questionnaire, what are 3 pharmacist contributions to transition of care? (3)

Answer 18

1. Medication knowledge
2. Knowledge on relevant programs
3. Familiarity with adult medical services

Question 19

According to a UK questionnaire, what are 3 identified barriers to transition of care for pharmacists? (3)

Answer 19

1. Time limitations
2. Pharmacists not being included in care teams
3. Lack of communication

Question 20

What are the pharmacist’s role in transition of care? (7)

Answer 20

1. Navigating insurance, support programs
2. Where/how to obtain prescription refills
3. Establishing goals of therapy
4. Educating on ‘self-care’
5. Medication education
6. Bridge between pediatric and adult services
7. Accessible