Authors :
Presenting Author: Sarah Stoney, MSW, LSW – Children's Hospital of Philadelphia
Summer Griffaton, BA – Children's Hospital of Philadelphia; Bethany Thomas, DNP – Children's Hospital of Philadelphia; Laurel Caffee, BA – Children's Hospital of Philadelphia; Adam Greenberg, MSN, CRNP – Children's Hospital of Philadelphia; Kerith Jangam, BS – Children's Hospital of Philadelphia; Nicole Hartmann, DO, MBS – University of Pennsylvania; Lawrence Fried, MD, MBA – Children's Hospital of Philadelphia; Marissa DiGiovine, MD – Children's Hospital of Philadelphia
Rationale:
Transitioning from pediatric to adult health care systems can be challenging for patients and families living with epilepsy. Based on needs assessment surveys that were distributed to adult providers and young adults who transitioned, a dedicated, social worker (SW) led transition clinic was created to address gaps in the transition process. We hope to improve the transition process by soliciting feedback from patients/caregivers that attended this clinic and from the adult epileptologists that assumed their care. Specifically, we hope to improve the anticipatory guidance we provide to patients/caregivers, about the transition process, and on differences in health care delivery in an adult health care system. Additionally, we believe that implementing this clinic will result in positive results from our adult care providers, as we hope to improve the transition process and create more informed patients/caregivers.Methods:
Referrals are received from the pediatric neurologist to initiate the transition process via the EHR (Electronic Health Record). The SW utilizes Microsoft Teams, a HIPAA-compliant platform, to hold non-billable video visits with patients and their families using curriculum developed from previous feedback received by the transition team. Appointments are approximately 60 minutes. In the video visit, the SW shares a PowerPoint presentation with the patient and family giving detailed information about the transition process. These tools allow patients/families to have a detailed conversation about transition using a visual guide. A key component to the visit is setting expectations of adult care practices, including how to prepare for an adult neurology visit and how to advocate for their own health care. A detailed psychosocial assessment is also completed. Patients/families are mailed a transition packet, with a medical summary and transition resources. Families are contacted once the appointment with the adult provider has taken place to solicit feedback and ensure follow through. In addition, surveys to patients/caregivers and adult providers will be distributed after the process is complete. Survey results are pending and data from this and other transitioned patients will be presented at the conference.Results:
Since the clinic launched two months ago, 35 patients have been referred: eight transition visits have been completed, four are scheduled, and twenty-three patients are awaiting scheduled. One patient has successfully completed the transition to adult care.Conclusions:
In response to recent data collected about the transition process, a dedicated transition clinic with a virtual appointment with social work was created. A transition clinic gives patients dedicated time, outside of clinical care, to discuss transition of care in detail, using feedback as the transition process is completed in further optimize the program.Funding:
Funding Source: HRSA Grant H98MC33238