Health Care Transition iTransition-Health : Self-Management Skills for Health Care

1. 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

2. 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.

3. 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.

4. INFORMATION WE’LL COVER • Health Care Transition • Increasing Youth Involvement in Managing Health and Wellness • Resources to Support Health Care Transition

5. 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)

6. 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

7. 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!

8. … 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

9. 2009/10 National Survey of Children with Special Health Care Needs Maryland Profile

10. 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 • YSHCN with single mothers Youth Transition to Adulthood Maryland rank: 40 Youth Health Care Transition For YSHCN in Maryland Data Sheet (data from NS-CSHCN)

11. HEALTH TRANSITION SURVEY AREAS

12. 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

13. 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.

14. 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?

15. 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…” • Explaintheir 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

16. 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

17. 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

18. 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

19. 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

20. 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!

25. RESOURCES FOR YOUTH AND YOUNG ADULTS

27. “Youth2YoungAdult” Care Notebookhttp://cshcn.org/planning-record-keeping/teen-care-notebook 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!

28. http://healthytransitionsny.org/skills_media/tool_show or google “Healthy Transitions New York”

29. CIRCLE OF SUPPORT VIDEO http://healthytransitionsny.org/skills_media/tool_show or google “Healthy Transitions New York”

30. SCHEDULING AN APPOINTMENT http://healthytransitionsny.org/skills_media/tool_show or google “Healthy Transitions New York”

31. MyMedSchedule.com https://secure.medactionplan.com/mymedschedule/index.htm

32. Maryland Transitioning Youth http://www.mdtransition.org/

33. RESOURCES FOR PARENTS, FAMILIES AND CAREGIVERS

34. My Heath Care Notebookhttp://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

35. Maryland Children and Youth with Special Health Care Needs Resource Locator http://specialneeds.dhmh.maryland.gov

36. http://www.gottransition.org/families-information or google “Got Transition?”

38. Transition to Adult Health Care: A Training Guide in Two Partshttp://www.waisman.wisc.edu/wrc/pdf/pubs/TAHC.pdf

39. http://new.dhh.louisiana.gov/assets/docs/OCDD/publications/EmergencyPreparednessTheTakeandGoEmergencyBook.pdfhttp://new.dhh.louisiana.gov/assets/docs/OCDD/publications/EmergencyPreparednessTheTakeandGoEmergencyBook.pdf

40. RESOURCES FOR PROVIDERS

41. http://www.gottransition.org/provider-information OR google “Got Transition?”

43. http://www.gottransition.org/6-core-Elements-Table or google“Got Transition?”Six Core Elements of Health Care Transition Pediatric Health Care Setting Adult Health Care Setting Young Adult Privacy and Consent Young Adult Patient Registry Transition Preparation Transition Planning Transition and Transfer of Care Transition Completion • Transition Policy • Transitioning Youth Registry • Transition Preparation • Transition Planning • Transition and Transfer of Care • Transition Completion

45. http://www.gottransition.org/UploadedFiles/Files/HCTClinicalReporteversion27June2011.pdfSupporting the Health Care Transition from Adolescence to Adulthood in the Medical Home

46. Payment for Health Care TransitionWork • 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) Health Care Transition Algorithm 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

47. Sample Health Care Transition Action Planhttp://www.gottransition.org/UploadedFiles/Files/4.1_Transition_Action_Plan.pdf - Link to document

48. Prevention and Health Promotion Administration Antoinette W. Coward antoinette.coward@maryland.gov 410-767-5602 http://phpa.dhmh.maryland.gov/

49. Prevention and Health Promotion Administration