Paving the Rocky Road Definitions for Young Adults: Guidelines - PowerPoint PPT Presentation

9/30/2016 Transitioning the adolescent with kidney disease Paving the Rocky Road • Definitions for Young Adults: • Guidelines A Unique Model of Care • Current understanding of transition • Transitional planning • Policy and insurance issues Elaine Ku, MD Assistant Professor University of California, San Francisco Departments of Medicine and Pediatrics Division of Nephrology and Pediatric Nephrology Outline Definition – the transitional process • Definitions • Transition ▫ “a purposeful, planned movement of adolescents • Guidelines and young adults with chronic physical and • Current understanding of transition medical conditions from child-centered to adult • Transitional planning oriented health-care systems” • Policy issues • Transfer ▫ “the act of moving from one provider to another or from one location to another” 1

9/30/2016 Outline • Definitions • Guidelines • Current understanding of transition • Transitional planning • Policy issues IPNA guidelines • Transfer should be ▫ Individualized for each patient after completion of transition plan (based on educational, social, and psychological attainment) ▫ Agreed jointly by patient and his/her family and pediatric and adult renal care teams ▫ Take place during a period without crises ▫ Take place after completing school education ▫ Take into account treatment plans by other subspecialties, especially with reference to urological supervision ▫ Take place with due consideration of financial factors Gottransition.org 2

9/30/2016 Transition checklist IPNA guidelines • Most effective time to transfer is after transition process ▫ Introduce concept of transition during early adolescence (12-14 years) ▫ Give information about transition in a gradual manner ▫ Directed by lead clinicians (“transition champions) ▫ Assigned to a nominated key worker responsible for coordinating transition ▫ Have an individualized transition plan ▫ Be offered informal visit to adult clinics 3

9/30/2016 IPNA guidelines IPNA guidelines • Transition or transfer clinic ▫ should include adult and pediatric nephrologists in attendance optimally ▫ Internal medicine specialist or nephrologist should take special interest and be trained in managing young people with advanced CKD ▫ Include comprehensive written and verbal summary of all aspects of young person’s care ▫ Young person should be prepared though a transition pathway to assert their autonomy 4

9/30/2016 Outline • Definitions • Guidelines • Current understanding of transition • Transitional planning • Policy issues Adolescent views on transition in diabetes and nephrology • Tong A, Eur J Ped, 2013 • Tong A, Eur J Ped, 2013 5

9/30/2016 Ped Nephrology April 2014 Adherence to IPNA guidelines Models of transition 6

9/30/2016 Models of transition Adherence and lack thereof • Average non-compliance rate is 32% in pooled studies • 43.2% if limited to adolescents • Accounts for 14 % of graft loss and 23% late acute P = 0.002 rejection episodes Core elements of transition Outline • Definitions • Guidelines ▫ General pediatrics ▫ Nephrology • Current understanding of transition ▫ In general pediatric patient ▫ In nephrology patient • Transitional planning • Policy issues Cooley W, 2014, JAMA Pediatrics 7

9/30/2016 Core elements of transition Transition registry Cooley W, 2014, JAMA Pediatrics Transition registry Core elements of transition Cooley W, 2014, JAMA Pediatrics 8

9/30/2016 Transition Team Division of Responsibilities • Elaine Ku, MD • Deborah Adey, MD Adult and Pediatric Nephrology Adult Kidney Transplant Age of Transition Clinic (based at Adult Kidney Transplant Lab follow-up Director, Transition Clinic patient BCH Mission Bay) Clinic (or adult local nephrologist if KTU clinic •Marissa Fleisch-Raymond, MD • Anthony Portale, MD only needed once a year) Adolescent Medicine Pediatric Kidney Transplant • Lisa Keung, RD • Danielle Krieger, NP 21 3 times a year 1 time a year Pediatric team Pediatric Renal Dietician Adult Kidney Transplant 22 2 times a year 2 times a year Pediatric team • Jessica Brennan, NP • Holly Synder, NP Pediatric Kidney Transplant Adult Kidney Transplant 23 1 time a year 3 times a year Pediatric team 24 Pediatric team is available to Assumes full responsibility Adult team • Marilyn McEnhill, NP • Elizabeth Wayne, NP support patient if needed Pediatric Kidney Transplant Adult Kidney Transplant • Taryn Shappell, LCWS • Amanda Watts, MSW Pediatric Social Worker Adult Social Worker • Sarah Baky, MSW Adult Social Worker Core elements of transition Transition Planning Cooley W, 2014, JAMA Pediatrics 9

9/30/2016 Medical Medical health passport health passport • https://www.sickkids.ca/myhealthpassport/ Core elements of transition Outline • Definitions • Guidelines ▫ General pediatrics ▫ Nephrology • Current understanding of transition ▫ In general pediatric patient ▫ In nephrology patient • Transitional planning • Policy issues, billing, and resources Cooley W, 2014, JAMA Pediatrics 10

9/30/2016 Insurance coverage Insurance options for young adults Policy issues • Staying on your parent’s plan until you are 26 years • Affordable Care Act old ▫ Improved access of young adults to health care insurance through • Medicaid coverage, depending on your income level Medicaid expansion in some states and the extension of and state dependent eligibility to age 26 years in private insurance plans ▫ elimination of lifetime caps on insurance benefits and preexisting • Job-based insurance coverage, if your employer conditions as obstacles to coverage provides it to you • Provider payment reform are needed to incentivize both • Student health insurance, depending on your school pediatric and adult providers to deliver high-quality transition care • Purchasing your own plan • Many transition services and supports such as patient • Resources education and care coordination fall outside of the usual ▫ http://health.younginvincibles.org/consumers-2/ encounter and procedure-based fee for service coding systems ▫ http://health.usnews.com/health-news/health- • The transition process may extend over a period in which both plans/articles/2011/01/13/best-affordable-health- pediatric and adult providers should be involved, requiring a insurance-options-for-young-adults mechanism for payment to bridge care 11

9/30/2016 Billing • CPT 99214 and 99215 for prolonged visits with > 50% visit spent on counseling • CPT codes 99374 (15–29 minutes) and 99375 ( >30 minutes) for “care plan oversight” - activity outside of office encounters involved in the management of a youth’s transition plan (whether it stands alone or is incorporated into a more general care plan for a chronic condition) constitutes “care plan oversight.” ▫ Phone calls to prospective adult primary care physicians or medical subspecialists ▫ conversations with the youth and family regarding transition plans, or communication with community agencies integral to the transition process 12