From Patients to Policy

1. From Patients to Policy Improving the Transition from Adolescent to Adult Medicine through Interprofessional Collaboration

2. Objectives

3. Who are we?

4. Who is ? • Founded in 1970 as People’s Free Clinic in an Austin church basement • Level 3 FederallyQualified HealthCenter • Patient-CenteredMedical Home • Community-Centered Health Home

5. DOCTOR PERSPECTIVE • Why is the guardian’s name still in the Demographics as the main contact when my patient is 23 years old? • What do I do about my 21 year old patient with Autism and Down Syndrome who doesn’t talk? • I’m trying to engage this 18 year old, but she keeps looking at her mother to answer all the questions. What do I do about patients who don’t want to grow up? • I’m tired of having to explain to guardians, patients, scheduling and front desk about all this consent and confidentiality stuff.

6. Patient Service Representative Perspective • Not having a process was very challenging for a front line staff member. • Placed in an uncomfortable situation. • Some situations presented a conflict between the patient and parent.

7. Health IT Perspective • We began work sessions that included several stakeholders to determine the departments that will be impacted. Health IT

8. Health IT Perspective continues… • The second phase of workgroups dropped off folks and added folks such as our Legal partner Keegan Warren Clem. Health IT

9. Health IT Perspective - Self Examining Questions • When does a patient become their own self-guarantor? • What if the patient is covered under their parents insurance? • When a patient requires parental assistance due to disabilities; who and where will this be documented? • How will we handle the patients who have not been seen in the last 18 months? • When will we transition this patient to the Adult Medicine department? • What type of education will we provide the patient to prepare them for adulthood?

10. Phase 2 • Many issues and exceptions to those issues surfaced that were nicely tabled for later discussion as Phase 2. • Lapse of care between that transition age (17-23) • Transitioning between different departments • Patient’s requesting to change providers

11. Integrated Legal Care through Medical-Legal Partnership Presented by Keegan Warren-Clem, JD, LLM

12. How Lawyers Resolve SDOH

13. What is medical-legal partnership (MLP)? • MLP is a healthcare delivery model that incorporates legal assistance into patient care. • MLP lawyers work onsite in the clinical or hospital setting as auxiliary members of the healthcare team. • Some MLP lawyers, particularlyin rural areas, work remotelyfrom a law office. • Favorable resolutions from national professional organizations. • American Academy of Pediatrics • American Medical Association • American Bar Association • American Academy of Family Physicians

14. MLP Nationally 155 hospitals 126 legal aid/nonprofits 139 health centers 52 law schools 34 health schools 64 pro bono partners

15. How HC Providers Collaborate in MLP

16. How Lawyers Collaborate in an MLP

17. Impact of MLP Participation Reported Anecdotally by Clinicians Notes: n=45-49 for clinicians and 42-53 for non-clinical staff. Data exclude “Don’t Know” responses. Source: 2016 NCMLP Survey.

18. Initial Premises • What is adulthood? • Texas law defines adulthood as someone who has reached the age of 18. An adult must make their own decisions. • There are exceptions: • Reproductive care • Court-ordered emancipation (ages 16+) • Mature minors • What is the public policy for decision-making? • Every adult should retain all rights of decision-making unless circumstances otherwise warrant.

20. Successful health care transition As a parent ourselves, we understood much planning and education was required if we wanted our adolescents and their family to experience a successful healthcare transition from Adolescence to Adulthood. Transition is a gradual process rather than an event. Some of the health care lessons that a patient will need to learn: • Communicating about their health care needs with providers and others • Preventive and responsible health behaviors • Health insurance and electronic health care record management • Legal rights and responsibilities • Community resources

21. Goals for internal training sessions • To implement a sustainable process for providing patients with the information they need to become a successful adult in making their own healthcare decisions and providing that information in a timely manner. • To adequately have their electronic health record reflect the changes that are required: • Financial guarantor • Medical consent forms • Release of Information • HIE form

22. Who….What….When Who: Front line staff (Call Center/Check-in/Check-out/Financial Counselors) Patients 18 years and older become a legal adult What: Documenting in the patient’s chart EPM and EHR chart When: 1 hour sessions This is an ongoing process. Patients will be identified through weekly reports; when scheduling an appointment; when checking in for an appointment.

23. Scheduling • Verify patient’s age (18 years and older) • RED TAG • Inform patient an additional appointment has been scheduled 30 minutes prior to their medical appointment. • Quick Note • Create a Quick Note with a list of items for patient to bring • Valid Photo ID • Medical Insurance card • Proof of address • Recent pay stubs (30 days) or proof of income. If zero income, a letter of support from an individual who is providing assistance. Note: All the information we ask for will help us determine the discount we can offer our young adult. It will also allow us to screen the patient through government and local health programs.

24. Appointment Book Payer for the Visit =RED TAG Red Tag =Redtag needs to be screened

25. Appointment Book continues…. Create a Quick Note Subject: Transition from Adolescence to Adulthood

26. Patient Arrival Begin with Address: Ask if the patient would prefer not to receive correspondence at their home. If the answer is NO, unselect.

28. Changing the Support Role At the patient’s discretion, a patient may designate one of their family members to be their support role. Support roles are also non-family members who play an important role in support of the patient.

29. Changing the Financial Guarantor Select the Guarantor Select Change Select the Person Select Self

30. Verify Insurance Coverage and SFDS • Patients are normally covered to age 25 under their parents insurance • Patient may now qualify for government and local funding • Patients Family Size has changed

31. Updated Forms Registration Form Consent to treat Insurance card Photo ID Along with other forms Adolescent Packet PCC contact services card (wallet size) Letter “What Happens when you turn 18 years old” Decision-Making, You and the Law

32. Adolescent Transition Packet • PSR’s will document YES/NO in the Adolescent Transition Packet field in EPM • This field is viewable by Providers in EHR by selecting the patient’s name from the Patient Information Bar

33. Community Engagement • Legal Community Support • Texas Healthy Adolescent Initiative Grant through Texas Department of State Health Services & Title V • Youth Adult/Advisory Council • Importance of Community and Youth Engagement

34. LESSONS LEARNED • Staff recognition of problem • Interdisciplinary team required to solve • Took longer than expected • Seemed pertinent to one department, but will affect entire clinic in positive way • Requires ongoing monitoring • Legal rights, consent, and confidentiality are complicated and often overlooked in the health care system, especially for adolescents and young adults

35. Video Actors Ann Marie Wilke, Youth Health Innovation Coordinator Vanessa Rojas, Health Application Analyst Gabrielle Rajulu, Volunteer Office Assistant Supreet Dhoat, Health Application Analyst Arturo Gonzalez, Health Information Management Sula Garza, Director of Health Information Services Workgroup Participants Kitty Ho, Thai Special Projects Coordinator YAC – Youth Advisory Council Alex Berry, Director of Compliance Sarah Murga, Practice Manager Rudy Turrubiartes, Health Application Analyst Stephanie Pariser, Revenue Cycle Manager Phase 2 – Dr. Mariela Lane, Physician Director of Adult Medicine Lilly Mitchell, Director of Quality, Quality & Compliance Amy Reed, Health Information Management Supervisor Contact Information Celia Neavel,MD,FSAHM,FAAFP Medical Director, Center for Adolescent Health & GOALS Top Doctor, Adolescent Medicine, Austin Monthly 2018 (VM)512-478-4939 ex1852 (Fax)512-320-0702 celian@austinpcc.org (Twitter)@CNeavelMD Keegan Warren-Clem, JD, LLM Managing Attorney, Austin Medical-Legal Partnership (512) 684-1714 (Office) (512) 477-6576 (Fax) Keegan@austinpcc.org Sula Garza, NCP Director of Health Information Services (512) 684-1705 (Office) (512) 320-0702 (Fax) sulac@austinpcc.org Araceli Ramos Patient Service Representative (512) 489-4939 (Office) (512) 320-0702 (Fax)

36. References 1. Adolescent Health A Guide for Providers Updated August 2016  Retrieved from https://www.dshs.texas.gov/thsteps/pdfdocs/AHG-08-2016.pdf 2. Got Transition website supported by The National Alliance to Advance Adolescent Health Retrieved from http://www.gottransition.org/ 3. Nehring, W. M. (2015, September-October. Uncharted Territory: Systematic Review of Providers' Roles, Understanding, and Views Pertaining to Health Care Transition. Journal of Pediatric Nursing 30 (5), 732-747  DOI: https://doi.org/10.1016/j.pedn.2015.05.030 4. Anna Arstein-Kerslake et al, Future Directions in Supported Decision-Making, 37 Disability Studies Quarterly (2017), available athttp://dsq-sds.org/article/view/5070/4549 (summarizing the policy trends informing shifts in the laws of legal personhood and capacity from a supranational, international, and national perspective). See generally National Center for Medical-Legal Partnership, http://medical-legalpartnership.org/ (last accessed Mar. 5, 2018). Advance Directives Act, Tex. Health & Safety code SS 166.001 et seq. Durable Power of Attorney Act, Tex. Estates Code § 751.001 et seq. Guardianship and Related Procedures, Tex. Estates Code § 1101.001 et seq. Supported Decision-Making Agreement Act, Tex. Estates Code § 1357.001 et seq. Declaration for Mental Health Treatment, Tex. Civ. Prac. & Rem. Code § 137.001 et seq.

37. Thank You