Transition Care Pearls

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

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

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

4. Self-care skills Education/employment Insurance status Access to adult health providers Successful Transition!! Self-care skills • 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. Self-care skills Education/employment Insurance status Access to adult health providers Successful Transition!! Education/employment • 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. Self-care skills Education/employment Insurance status Access to adult health providers Successful Transition!! Insurance status • 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. Self-care skills Education/employment Insurance status Access to adult health providers Successful Transition!! Access to Health Providers • 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 • 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)

9. How Much Primary Care Should We Provide? • 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 • 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 • If extensive primary care is needed, refer to ourselves at Simms or SMIMP

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

11. 20 yo with SLE stable on three meds 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 Case #1

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

13. 25 yo with mental retardation, chromosome 18 deletion, seizure disorder Osteopenia on DEXA, on Vit D Has straight Medi-Cal 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 Case #2

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

15. STAT consult 21 yo Turner’s syndrome on her birthday; would lose CCS next day Undocumented Sophomore in community college 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 Case #3

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

17. 20 yo with sickle cell and asthma Multiple ER visits for pain crises 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 Case #4 (trainwreck)

18. Overall Approach in TCP Clinic • Review chart on arrival • Go over two forms with patient—self-care skills rating and patient questionnaire • Present to attending • 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 • 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 • Focus on connecting pt with a PMD • Don’t need to look for individual specialists all over L.A. county or beyond • Pt needs to take responsibility for care as well • Bring back for return visits if necessary; discharge from clinic if possible

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

21. Questions? Discussion?