Health Care Transition
iTransition-Health: Self-Management Skills for Health Care
THE
GOVERNOR’S INTERAGENCY TRANSITION COUNCIL FOR YOUTH WITH
DISABILITIES
November 16, 2013
Maryland Department of Health and Mental Hygiene
Prevention and Health Promotion Administration
Antoinette W. Coward, MS, MCHES
Health Care Transition Coordinator
Office for Genetics and People with Special Health Care Needs
MISSION AND VISION
MISSION
• The mission of the Prevention and Health Promotion Administration is
to protect, promote and improve the health and well-being of all
Marylanders and their families through provision of public health
leadership and through community-based public health efforts in
partnership with local health departments, providers, community based
organizations, and public and private sector agencies, giving special
attention to at-risk and vulnerable populations.
VISION
• The Prevention and Health Promotion Administration envisions a future
in which all Marylanders and their families enjoy optimal health and
well-being.
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iTransition-Health
MISSION
• The mission of the Office for Genetics and People with Special Health
Care Needs’ Health Care Transition Program (iTransition-Health) is to
promote and improve health care transition services for Maryland
youth and young adults with special health care needs (12 to 26 years
old).
VISION
• The Health Care Transition Program envisions a future in which
Maryland youth and young adults with special health care needs in
partnership with their families and providers has established health
care transition plans leading to continuous health care access.
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INFORMATION WE’LL COVER

Health Care Transition

Increasing Youth Involvement in Managing
Health and Wellness

Resources to Support Health Care
Transition
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HEALTH CARE TRANSITION
Health care transition is helping young people with special
health care needs plan their move from the child-centered
health care system to the adult-centered health care
system. Some ways that this is done include:
• Current doctors and health care providers discussing changing
health care needs as youth become adults and eventually see
adult providers
• Doctors, other health care providers, and families encouraging
youth development toward self-management skills and
knowledge
• Families, youth, and providers working together on a written
Transition Plan(s)
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DEFINITION FOR CSHCN
Children with Special Health Care Needs
(CSHCN) are children; children who happen
to need extra care

Who have or are at increased risk for chronic
physical, developmental, behavioral, or
emotional conditions

Who require health and related services of a
type or amount beyond that required by children
generally
Maternal and Child Health Bureau, US Department of Health and Human Services, (Cooperative Agreement MCU-06 MCP1),
July 1,1998
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Children with Special Health Care
Needs in Maryland
244,000 children
have special health
care needs in
Maryland, which is
the equivalent of
enough children to
fill 3.5 Baltimore
Ravens Stadiums!
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… and almost 1 in 4
households with children
(23.1%) have at least one
CYSHCN
18.2% have
one CYSHCN
4.9% have
two or more
CYSHCN
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2009/10 National Survey of Children with Special Health Care Needs
Maryland Profile
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Youth Transition to
Adulthood
Groups less likely to receive
services necessary for a
successful transition:
•Black YSHCN
•YSHCN ages 15-17 years
•YSHCN with emotional,
behavioral or developmental
issues
•YSHCN with inadequate
insurance
•YSHCN without a medical home
Maryland
rank: 40
•YSHCN with single mothers
Youth Health Care Transition For YSHCN in Maryland Data Sheet (data from NS-CSHCN)
HEALTH TRANSITION
SURVEY AREAS
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2012 MARYLAND TRANSITIONING
YOUTH PARENT SURVEY
Almost 49% of YSHCN families report having
participated in some type of transition planning for
their child; of these:
• 72% participated in transition planning through
their child’s IEP only
• 2.7% participated in health care transition
planning only
• and 25% participated in transition planning
through their child’s IEP and also participated in
health care transition planning
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TRANSITION PLANNING
• Developing a transition plan for YSHCN is an
important tool in the process of moving to
adulthood
• Including health care in the transition plan, or
developing a separate health care transition plan
with care providers, is crucial.
• Health care transition planning should be done
by youth, families, and providers.
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INDEPENDENCE WITH SUPPORT
Health and WelIness 101: The Basic Skills
to support independence:
 Knowledge of Health Issues/Diagnosis
 Being Prepared
 Taking Charge
 After Age 18 Skills
Source: Got Transition?
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INDEPENDENCE WITH SUPPORT
If possible, teens and young adult should be
able to:
 Understand their own condition and the
treatment or intervention needed – “I have
cerebral palsy because I lost oxygen
at birth… I need help with…”
 Explain their condition and needed treatment or
intervention to others – “I am on three
medications for spasticity.”
Source: Transition to Adult Health Care: A Training Guide in Two Parts. Waisman Center, University of Wisconsin-Madison
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INDEPENDENCE WITH SUPPORT

Monitor their health status on an ongoing basis
– “I use my communication device to let others
know how I am feeling.”

Ask for guidance from their pediatric health
care providers on how and when to make the
move from pediatrics to adult care – “I’m going
to ask my pediatrician- when should I start
seeing a family practice doctor for my general
care instead of a pediatrician?”
Source: Transition to Adult Health Care: A Training Guide in Two Parts. Waisman Center, University of Wisconsin-Madison
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INDEPENDENCE WITH SUPPORT

Learn about the systems (and the importance of
them) that will apply to them as adults, such as
health insurance, social security and other
programs; as well as issues like guardianship
and power of attorney for health care –
“I have applied for medical assistance through
Social Security for now because I have a
disability and I need to be able to get medical
Source: Transition to Adult Health Care: A Training Guide in Two Parts. Waisman Center, University of Wisconsin-Madison
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INDEPENDENCE WITH SUPPORT

Identify both formal and informal advocacy
services and supports they may need in order to
be as independent as possible while at the same
time using trusted advisors and mentors –

“I ask my parents for advice because they have
known my medical care the longest.”
Remember to Reward Efforts!
Source: Transition to Adult Health Care: A Training Guide in Two Parts. Waisman Center, University of Wisconsin-Madison
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Start small. Start slow. Start now!
How do you prepare your teens to meet
the challenges of adult health care? By
using ordinary, every day teaching
opportunities and lots of practice.
“Just because a thing is inconceivable
doesn’t mean it’s impossible.” – Lewis
Carroll
Source: Transition to Adult Health Care: A Training Guide in Two Parts. Waisman Center, University of Wisconsin-Madison
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www.gottransition.org
•Compare your answers with your family. They might be surprised what you know or what you want to learn.
•Work on a plan to increase your health care skills. Share with the medical team the skills that you are working on.
•It takes time and practice to learn and demonstrate these skills. Best time to start, is today!
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Yes
I do
this
3. My child knows his/her health and
wellness baseline
(pulse, respiration rate, elimination habits)
4. My child knows health symptoms that
need quick medical attention.
5. My child knows what to do in case he/she
have a medical emergency
BEING PREPARED
6. My child carries his/her health insurance
card everyday
7. My child carries his/her important health
information with me everyday
(i.e.: medical summary, including medical
diagnosis, list of medications, allergy info.,
doctor’s numbers, drug store number, etc.)
I
want
to do
this
I
need
to
learn
how
Someone
else will
have to
do this Who?
Yes
I do
this
TAKING CHARGE
8. My child calls for his/her my own doctor
appointments.
9.
My child knows he/she has an option to see
the doctor by him/herself.
10. Before a doctor’s appointment my child
prepares written questions to ask.
11. My child track his/her own appointments &
prescription refills expiration dates.
12. My child calls in his/her own prescriptions
refills.
I
want
to do
this
I
need
to
learn
how
Someone
else will
have to
do this Who?
Yes
I do
this
13. My child has a part in filing medical
records and receipts at home.
14. My child pays for the co-pays for
medical visits.
15. My child co-signs the “permission for
medical treatment” form (with or without
signature stamp) or can direct others to do
so).
16. My child helps monitor his/her medical
equipment so it’s in good working condition
(daily and routine maintenance).
I want
to do
this
I
need
to
learn
how
Someone
else will
have to
do this Who?
Yes
I do
this
AFTER AGE 18
17. My child and our family have a plan so
he/she can keep my healthcare insurance
after turning 18 and 26.
18. My child will be prepared to sign
his/her own medical forms (HIPAA,
permission for treatment, release of
records)
19. My child and our family have discussed
and plan to develop a legal Power of
Attorney for health care decisions in the
event health changes and he/she is unable
to make decisions for them self. (Everyone
in the family should have one!)
I want I
to do need
this
to
learn
how
Someone
else will
have to
do this Who?
RESOURCES FOR YOUTH AND
YOUNG ADULTS
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AGES 12 – 14 “New Responsibilities”
AGES 15 – 17 “Practicing Independence”
AGES 18 & UP “Taking Charge
“Youth2YoungAdult” Care Notebook
http://cshcn.org/planning-record-keeping/teen-carenotebook
This resource is on the flash
drive bracelets you
received today.
It can help youth/ young
adults manage aspects of
their own health care.
It contains pre-made, fillable
forms for:
Medications
Appointment Logs
Care Schedule
Home Care Providers
Hospital Information
Insurance/Funding
Sources form
• Equipment and
Supplies List
• And more!
•
•
•
•
•
•
http://healthytransitionsny.org/skills_media/tool_show or google “Healthy
Transitions New York”
CIRCLE OF SUPPORT VIDEO
http://healthytransitionsny.org/skills_media/tool_show or google “Healthy Transitions New York”
SCHEDULING AN APPOINTMENT
http://healthytransitionsny.org/skills_media/tool_show or google “Healthy Transitions New York”
MyMedSchedule.com
https://secure.medactionplan.com/mymedschedule/index.htm
Maryland Transitioning Youth http://www.mdtransition.org/
RESOURCES FOR PARENTS, FAMILIES
AND CAREGIVERS
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My Heath Care Notebook
http://fha.dhmh.maryland.gov/genetics/SitePages/care_notebook.aspx
This resource is also on
the flash drive
bracelets you received
today.
It can help parents
manage aspects of
their child and or
youth’s health care.
It contains pre-made,
fillable forms
Maryland Children and Youth with Special Health Care Needs
Resource Locator http://specialneeds.dhmh.maryland.gov
http://www.gottransition.org/families-information or google “Got Transition?”
Transition to Adult Health Care: A Training Guide in Two Parts
http://www.waisman.wisc.edu/wrc/pdf/pubs/TAHC.pdf
http://new.dhh.louisiana.gov/assets/docs/OCDD/publications/EmergencyPreparednes
sTheTakeandGoEmergencyBook.pdf
RESOURCES FOR PROVIDERS
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http://www.gottransition.org/provider-information OR google “Got Transition?”
http://www.gottransition.org/6-core-Elements-Table or google
“Got Transition?”
Six Core Elements of Health Care Transition
Pediatric Health Care Setting
1.
2.
3.
4.
5.
6.
Transition Policy
Transitioning Youth
Registry
Transition Preparation
Transition Planning
Transition and Transfer
of Care
Transition Completion
Adult Health Care Setting
Young Adult Privacy
and Consent
2. Young Adult Patient
Registry
3. Transition Preparation
4. Transition Planning
5. Transition and Transfer
of Care
6. Transition Completion
1.
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http://www.gottransition.org/UploadedFiles/Files/HCTClinicalReporteversion27June2
011.pdf Supporting the Health Care Transition from Adolescence to Adulthood in the
Medical Home
Payment for Health Care
TransitionWork
Health Care Transition Algorithm
•For YSHCN who require periodic
chronic condition management
(CCM) visits, health care transition
(HCT) planning and preparation are
to be included in these visits – can be
billed using CPT codes 99214 or
99215 (prolonged encounter codes);
•For care plan oversight billing
(provider activities that take place
outside of office encounters with the
patient – i.e. phone calls to
prospective adult providers,
conversations with the youth and
family regarding transition plans, or
communicating with community
agencies involved in the youth’s
transition) use care plan oversight
CPT codes 99374 (15-29 minutes) or
99375 (≥30 minutes)
Source: Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics 2011;
128; 182. http://pediatrics.aappublications.org/content/128/1/182.full.html
Sample Health Care Transition Action Plan
http://www.gottransition.org/UploadedFiles/Files/4.1_Transition_Action_Plan.pdf Link to document
Prevention and
Health Promotion
Administration
Antoinette W. Coward
[email protected]
410-767-5602
http://phpa.dhmh.maryland.gov/
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Prevention and
Health Promotion
Administration
http://phpa.dhmh.maryland.gov
Prevention and Health Promotion Administration
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