Transition to Adulthood: Future Directions in Professional Education

1. Transition to Adulthood:Future Directions in Professional Education Kitty O’Hare, MD Internal Medicine-Pediatrics Assistant Professor, Harvard Medical School

2. Disclosures Ihave no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

4. Educate:Latin “educere”- to lead forth Merriam-Webster Dictionary

5. Agenda • Review the literature • Examples of educational models and curricula • Apply educational theory to transition

6. Let us pick up our books and our pens. They are our most powerful weapons. Malalayousafzai

7. 2002 Consensus Statement Identified 6 priorities for improving young adult transitions, including: “Train primary care providers in transition services” AAP/AAFP/ACP-ASIM. A Consensus Statement on Health Care Transitions for Young Adults With Special Health Care Needs. Pediatrics 2002; 110:1304-6.

8. 2011 Consensus Statement • Identified 6 areas for quality improvement, including: “Promotion of training and clinical experience on transition and transfer of youth and young adults (both with and without special needs) for trainees in all medical fields.” Transitions Clinical Report Authoring Group, Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home. Pediatrics 2011; 128:181-202.

9. Internists’ Perspectives on Transition • Random survey of U.S. board-certified Internists • Asked to name and rank their concerns about transition 2 out of 5 top concerns related to training Peter NG et al. Transition from Pediatric to Adult Care: Internists’ Perspectives. Pediatrics 2009; 123:417-23.

11. Barriers to Care: Internists vs Pediatricians Training as a factor limiting ability to care for young adults with childhood-onset chronic disease • Internists: Ranked 4 out of 9 • Pediatricians: Ranked 6 out of 9 • Omukura MJ, et al. Physician Views on Barriers to Primary Care for Young Adults With Childhood-Onset Chronic Disease. Pediatrics 2010; 125:e748-54).

12. Comfort with Childhood-Onset Chronic Disease • Survey of 1288 U.S. internists and pediatricians • Assessed comfort with providing primary care for patients with sickle cell disease or cystic fibrosis Okumura MJ, et al, Comfort of General Internists and General Pediatricians in Providing Care for Young Adults with Chronic Illnesses of Childhood. J Gen Intern Med 2008; 23:1621-7.

15. Odds Ratio for Comfort to Treat in Primary Care

17. Resident Comfort with Outpatients Patel MS and O’Hare K. Residency Training in Transition of Youth with Childhood-Onset Chronic Disease. Pediatrics 2010; 126 S3:S190-3.

18. Likelihood to Provide Care after Residency Patel MS and O’Hare K. Residency Training in Transition of Youth with Childhood-Onset Chronic Disease. Pediatrics 2010; 126 S3:S190-3.

19. Adolescent Medicine Training in 145 Pediatric Residency Programs 14% 17% 33% 37% 50% 49% Chronic Illness Handoffs to Adult Care • Fox HB, et al. Adolescent Medicine Training in Pediatric Residency Programs. Pediatrics 2010; 125:165-72.

20. Adolescent Medicine Training in 145 Pediatric Residency Programs 14% 17% 33% 37% 50% 49% Chronic Illness Handoffs to Adult Care • Fox HB, et al. Adolescent Medicine Training in Pediatric Residency Programs. Pediatrics 2010; 125:165-72.

21. Pediatric Resident Education in CSHCN Nazarian B, et al. Identifying What Pediatric Residents Are Taught About Children and Youth With Special Health Care Needs and the Medical Home. Pediatrics 2010; 126: S183-9.

22. South Carolina: Resident Preferences for Transition Curriculum Mennito S. Resident preferences for a curriculum in healthcare transitions for young adults. South Med J 2012; 105:462-6.

23. University of Alabama: Development of a Transition Course Key insights: 1. Need to include the voices of patients and families 2. Use of faculty from various professions and specialties to model interdisciplinary care 3. Insight that problems specific to transition offer into contemporary health care financing Hagood JS, et al. A course on the transition to adult care of patients with childhood-onset chronic illnesses. Acad Med 2005; 80:352-5.

24. He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all. William Osler

25. Harvard Longwood Med-Peds Crossover Curriculum • Authors: Zadok Sacks MD, Anna Volerman MD,Niraj Sharma MD MPH • Learners: Med-Peds, Pediatrics and Internal Medicine residents • Format: Resident report conferences featuring guest faculty from the opposite discipline (e.g. adult cardiologist at pediatrics report)

26. Feedback from Pilot (n=70 IM residents) Quantitative Qualitative “I feel much more knowledgeable on [inflammatory bowel disease] and [cystic fibrosis] and would feel more comfortable when taking care of adult patients with those diseases.” “I will trust a sickle cell patient to tell me what dose of pain meds works for them in a pain crisis.” “[I will be] more sensitive to [the] transition years.” • 87% had no prior training related to the transitioning of YSHCN • 99% stated that hearing from pediatrics subspecialists about these topics enhanced their learning • 98% felt that the CC adds to their education

28. Brigham & Women’s/Boston Children’s Hospital Transition to Adult Care Conference • Authors: Kitty O’Hare, MD and Niraj Sharma, MD MPH • Learners: Physicians, nurses, social workers, trainees >200 on list-serv; across Massachusetts and Rhode Island • Format: Monthly interdisciplinary conference

29. 2014-15 Themes

30. 2014-15 Themes

31. 2014-15 Themes

32. 2014-15 Themes

33. Boston Children’s Hospital Primary Care • Author:Kitty O’Hare, MD • Learners: Pediatrics and Med-Peds residents • Format: Continuity clinic teaching case: a 17yo with Down Syndrome

34. Harvard Medical School Tutorial • Authors: Niraj Sharma, MD MPH • Learners: Medical students • Format: Small group learning Case: a 19yo with cystic fibrosis

35. AAMC MedEdPORTAL • Author: Laurie Fishman, MD But Tommy Likes It Here: Moving to Adult MedicineMedEdPORTALPublications; 2012. www.mededportal.org/​publication/​9190 • Learners: Healthcare professionals, trainees • Format: Cases in small group format

36. MUSC Transition Elective • Author: Sarah H. Mennito, MD MSCR • Learners: Med-Peds residents • Format: Month-long ambulatory rotation Subspecialty clinics, literature review, case review, project

37. Baystate • Authors: Matthew Sadoff, MD • Learners: Pediatrics, Internal Medicine, and Med-Peds residents Medical students • Format: Clinical rotation for children with medical complexity Approach to children with medical complexity Sadof M, et al. The “HEADS AT” Training Tool for Residents: A Roadmap for Caring for Children With Medical Complexity. ClinPediatr 2014.

38. University of South Florida • Author: Janet Hess, DrPH, MPH, CHES • Learners: Pediatric and Med-Peds residents • Format: Pilot QI initiative Multi-level intervention 1. Didactic session 2. Patient transition education materials made available in clinic 3. Transition tool made available in the EHR

39. Children’s Mercy Hospital and ClinicsSocial Work Education • Author: Terri Hickam, LCSW, LSCSW, CCM • Learners: Social workers • Format: Guardianship training course for staff Establishing scope of practice for social workers in a team-based approach to transition

40. Duke Children’s ATLAS: Adolescents Transitioning to Leadership and Success • Authors: Gary Maslow, MD MPH & Amanda Rozycki, MSW • Learners: Pediatrics residents, medical students, college students • Format: Monthly support group for YSHCN

41. AnMed, South CarolinaMedical Students as Transition Coaches for YSHCN • Authors: Nathan F. Bradford, MD and Brian Mulroy, DO • Learners: 3rd Year Medical students • Format: Students assigned to coach a YSHCN as they are leaving pediatrics to enter family medicine

42. Got Transition? • Authors: www.gottransition.org • Learners: Physicians, practicing and in training • Format: Dr. Right/Dr. Knotright YouTube videos- examples of how transition discussions can be done well (or poorly)

43. Illinois Chapter of the AAPOnline CME and MOC Part IV • Authors: Illinois Chapter of the AAP http://illinoisaap.org/projects/medical-home/transition/ • Learners: Practicing Pediatricians, Internists and Family Medicine physicians • Format: Web-based CME

44. FloridaHATS Training for Health Care Professionals • Authors: FloridaHATS http://www.floridahats.org/?page_id=2206 • Learners: Physicians and Allied Health Professionals • Format: 10 online modules for CME/CE

45. University of FloridaOnline graduate certificate in transition education • Authors: University of Florida College of Education http://education.ufl.edu/education-healthcare-transition/certificate-program/ • Learners: Allied health professional students • Format: Online fee-for-enrollment certificate program

46. CHIPRA Massachusetts Medical Home Collaborative • Authors: NICHQ, Boston Children’s Hospital, Massachusetts Health Quality Partners, MassHealth and the University of Massachusetts Medical School http://medicalhome.nichq.org/solutions/chipra-medical-home • Learners: 13 inter-disciplinary teams from primary care pediatrics • Format: In-person learning sessions and conference calls

47. Education is the most powerful weapon which you can use to change the world. Nelson Mandela

48. 2014 Match Data NMPRA 2014 Match Data, http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf.

49. Physician Education Training Requirements Sharma N, O'Hare K, Antonelli RC, Sawicki GS. AcadPediatr. 2014 Mar-Apr;14(2):120-7.

50. Future of Physician Education Sharma N, O'Hare K, Antonelli RC, Sawicki GS. AcadPediatr. 2014 Mar-Apr;14(2):120-7.