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Hawai ‘ i Title V State Performance Measure: Transition Progress Patricia Heu, MD, MPH

Hawai ‘ i Title V State Performance Measure: Transition Progress Patricia Heu, MD, MPH Chief, Children with Special Health Needs Branch Title V CSHCN Hawai‘i State Department of Health pat.heu@fhsd.health.state.hi.us October 16, 2007. Transition Guiding Principles For Hawai‘i State Team.

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Hawai ‘ i Title V State Performance Measure: Transition Progress Patricia Heu, MD, MPH

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  1. Hawai‘i Title V State Performance Measure: Transition Progress Patricia Heu, MD, MPH Chief, Children with Special Health Needs Branch Title V CSHCN Hawai‘i State Department of Health pat.heu@fhsd.health.state.hi.us October 16, 2007

  2. Transition Guiding Principles For Hawai‘i State Team • Guiding principles include: • Transition of children/youth with special health care needs & their family requires a collaborative partnership between families and professionals involved. • Transition is a shared responsibility between family and professionals, with varying degrees of accountability over time. • The foundation for successful transition begins in early childhood.

  3. Approach For Hawai‘i Transition Activities Based on BDI (Behaviors, Determinants, & Interventions) Logic Model Youth/families have a transition plan & work toward adult life. Professionals assist & support YSHCN/families in transition. Health providers facilitate the transition of YSHCN to adult health care. Increase knowledge & skills for families, professional partners, & health care providers regarding transition Goal: YSHCN transition to adult life, including adult health care, work, & independence Which, In Turn, Promotes That Affect Activities related to transition Affect

  4. Hawai‘i State Performance Measure on Transition Score 0-4 Scoring: • 0 Activities have not begun • 1 Activities have just begun • Activities are progressing • Activities are well-established • Activities are sustained

  5. Activity Rainbow Book Resource Guide Document best practices & protocols for coordinated care between programs. Increase knowledge of families & professionals about state/community resources for YSHCN/families. • Rainbow Book addresses need for access to resource information, to facilitate transitions. • Workshops have various programs/agencies training together. Includes test & certification. • Evaluation: • 90% (99/110) use book to learn about services, give information to others, make a referral. • 97% (107/110) now know more about services for CSHCN.

  6. Activity Training and Supports for Families Provide Navigating the System training to families of children 0-3 years & YSHCN. Increase knowledge of families & professionals about supports for transitions along life’s journey. • Family Convergence 2006 conference. • Successful Parent-Child-Physician Partnerships • Transitioning–Life After Early Intervention • Transitioning–Life After High School • Workshops on Natural Supports for families. • Workshop for family leaders on training practices & tips. • Training on 0-3 early intervention transition to special education • Transition planning workshops.

  7. Activity Youth Advisory Council (YAC) Establish and facilitate a Youth Advisory Council. Develop youth personal leadership, self-determination, & advocacy skills. • YAC purpose – advise Hilopa‘a Project, build skills of personal leadership, self determination, & community advocacy. • YAC includes both youth with disability and typical youth with affinity or relationship with individual with disability. • Youths provide legislative testimony, write letters to newspaper editor, and plan/host a “briefing” for policy makers on their priority issues.

  8. Activity Best Practices on Transitioning Best policies & practices on transitioning YSHCN to adult health care. Increase knowledge of health care providers and health plans about transition to adult life. • Working with providers, health plans, & Medicaid on developing protocols & service models for transition. • Briefing with Internal Medicine-Pediatric physicians. • Discussion with Health Plan Medical Directors of the Pediatric Council. • Personal Health Record.

  9. Activity Transition Training for Physicians-in-Training Provide a medical home curriculum that includes transition, to be incorporated into training for residents. Increase knowledge of residents about transition of YSHCN to adult life, including adult health care and medical home role in transition. • Training for pediatric & family practice residents on medical home role in supporting families through transition process. • Residents present information & best practice medical home case scenario related to transition to adult life. • Noon Conference presentation with national experts. • Rainbow Book training for residents.

  10. Activity Transition Planning Workbook Increase knowledge of families & professionals about supports for transitions along life’s journey and planning for transition to adult life. Develop transition planning workbook for families & programs/agencies. • “Talk story” guide about the planning process of transitioning youth to adult life. • Tasks & decisions • Transition activity timeline • Health & other resources • Health & life skills • Families can create a workplan on how to address issues over a period of time. • Workshops for families and professional partners.

  11. Increase knowledge of families & professionals about supports for transitions along life’s journey and planning for transition to adult life. Youth & their families have a transition plan & work toward adult life. Professionals assist & support YSHCN & their families in transition to adult life. Health providers facilitate the transition of YSHCN to adult health care. Increase knowledge of families & professionals about state/community resources for YSHCN/families. YSHCN transition to adult life, including adult health care, work, & independence Develop youth personal leadership, self-determination & advocacy skills. Increase knowledge of pediatric & family practice residents, health care providers, and health plans about transition to adult life. Logic Model For Hawai‘i State Performance Measure on Transition Activity Community & Individual Determinants Behavior Goal Provide Navigating the System training to families of children 0-3 years & YSHCN. Develop transition planning workbook for families & programs/agencies. Document best practices & protocols for coordinated care between programs. Certification, based on Rainbow Book. Establish and facilitate a Youth Advisory Council. Provide training on transition for pediatric & family practice residents. Best policies & practices on transitioning YSHCN to adult health care.

  12. The transitions of children & youth with special health care needs and their families should be successful and celebrated. Josie Woll 2005

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