You main objectives are to:
- Establish criteria and process for identifying transition-aged youth/young adults .
- Develop process to track receipt of the Six Core Elements, integrating with electronic medical records (EMR) when possible
The PDF in the “Materials” folder above is a great tool for implementing tracking and monitoring. Here is an except.
“What information might be included in tracking and monitoring? Below are some questions and ideas to think about.
• Demographic and diagnostic information (e.g., name, date of birth, age, diagnosis). • Medical (e.g., disease complexity including utilization) and social complexity information (e.g., social determinants of health/adverse childhood experiences) information. This information will be helpful to risk stratify your transition-aged population.1-3
Date of receipt of each core element, including:
- When the transition and care policy/guide was shared with youth/young adult and parent/caregiver o When the HCT readiness/self-care skills assessment was administered
- When the HCT readiness/self-care skills education was provided o When the HCT plan of care was shared with youth/young adult/parent/caregiver
- When the medical summary and emergency care plan were shared with youth/young adult/parent/caregiver o When the age 18 privacy and consent changes were discussed o When supported decision-making (if needed) was discussed
- When feedback was elicited from youth/young adult/parent/caregiver about the HCT supports received in your practice
PROCESS What is the process to implement tracking and monitoring? Below are some questions and ideas to think about.
- Develop criteria for what youth/young adults will be a part of this transition registry. Will it include all transition-aged youth/young adults or will it include youth/young adult with selected chronic conditions?
- Decide at what age the registry will begin to track the youth/young adult’s receipt of HCT services. • Decide what patient data should be tracked. Will a complexity score or level be used? If so, will it include a combination of medical and social complexity scores?
- Choose the format. Will it be an individual flow sheet or a registry via your EMR, REDCap, or an Excel spreadsheet? (See examples in Section III. Due to the variety and proprietary nature of EMRs, none can be provided as an example.)
- Work with your practice/system to decide who will input the data and how progress will be monitored. Will the team or the individual clinician be monitoring if all HCT services were offered? If not, who will be responsible for ensuring all services are provided?
- Create a written document to describe the clinic approach to implement the process outlined above
- Educate all team members/staff about the process.”
