Transcript Transition from Adolescent to Adult HIV Care – Practices

Transition from Adolescent to Adult
HIV Care – Practices & Pitfalls
Tess Barton, MD – University of Texas Southwestern,
Dallas, TX
Ana Puga, MD – Children’s Diagnostic & Treatment
Center, Fort Lauderdale, FL
June Trimble - University of Texas Southwestern,
Dallas, TX
Disclosures
• Tess Barton, MD
– Has no financial interests or relationships to disclose
• Ana Puga, MD
– Speaker Bureau: Gilead, Abbott, Simply Speaking HIV
CME
• June Trimble
– Has no financial interests or relationships to disclose
Learning Objectives
• At the conclusion of this activity, the
participant will be able to:
1. Describe steps taken in creating a smooth
transition from one care provider to another
2. Identify 3 barriers to successful transition
3. Apply methods taught in the session to
circumstances in local health care settings
Obtaining CME/CE Credits
• If you would like to receive continuing
education credit for this activity, please visit:
http://www.pesge.com/RyanWhite2012
Workshop Schedule
1. Overview of transitioning topic, including
review of recommended practices and
challenges (30 min)
2. Small group activity (40 min)
3. Summary (5 min)
4. Questions (15 min)
Why Is a Transition Process Needed?
• Deliberate, planned process that addresses the
medical, psychosocial, vocational, and
educational needs of adolescents and young
adults with chronic conditions when moving from
a pediatric service to adult-oriented care (Rosen,
et. al. Journal of Adolescent Health, 2003)
• Adolescent development
– Maturity
– Autonomy
• Shift from pediatric to adult healthcare funding
General Principles
• Youth should understand the basic biology of
HIV, why their medications and treatments are
necessary, and how to prevent transmission
• Informed decision-making is the key to mature
self-care and is the overall goal for successful
transitioning
New York State Department of Health AIDS Institute: www.hivguidelines.org
General Principles
• Individualize the approach used
• Identify adult care providers who are willing to care for
adolescents and young adults
• Begin the transition process early and ensure
communication between the pediatric/adolescent and
adult care providers prior to and during transition
• Develop and follow an individualized transition plan for the
patient in the pediatric/adolescent clinic; develop and
follow an orientation plan in the adult clinic. Plans should
be flexible to meet the adolescent’s needs
New York State Department of Health AIDS Institute: www.hivguidelines.org
General Principles
• Use a multidisciplinary transition team, which may
include peers who are in the process of transitioning or
who have transitioned successfully
• Address comprehensive care needs as part of
transition, including medical, psychosocial, and
financial aspects of transitioning
• Allow adolescents to express their opinions
• Educate HIV care teams and staff about transitioning
New York State Department of Health AIDS Institute: www.hivguidelines.org
Basic Steps in Transitioning
Assess youth readiness & skills
Prepare youth for transition process
Engage members of transition team
Transfer care
Follow-up & evaluation
Basic Steps in Transitioning
Assess youth readiness & skills
Prepare youth for transition process
• Begin transition planning at least 3
years before
expected
transition, team
if
Engage
members
of transition
possible
• Transition checklist tools available
care
• Review andTransfer
modify the
plan annually
• Involve family, caregivers
• Incorporate mental health assessments
Follow-up & evaluation
Basic Steps in Transitioning
Prepare youth for transition process
• Know when to seek medical care for symptoms or emergencies
• Make, Engage
cancel, andmembers
reschedule appointments
of transition team
• Arrive to appointments on time
• Call ahead of time for urgent visits
• Request prescription refills
correctly
Transfer
care
• Negotiate multiple providers and subspecialty visits
• Understand health insurance, how to obtain it and renew it
• Understand entitlements and know how to access them
Follow-up & evaluation
• Establish a good working relationship with a case manager
Basic Steps in Transitioning
Assess
youth
readiness
&
skills
Prepare youth for transition process
• Pediatric/adolescent care team should consider implementing
members
of transition
team
aEngage
more structured
appointment
system before
transition to
promote skills building and to minimize “culture shock”
• Policies are generally followed more strictly in adult care
Transfer care
• Peer support groups
• Skills practice sessions with medical students and residents
Follow-up & evaluation
Basic Steps in Transitioning
• Multidisciplinary team
• Pick the right adult provider
• Accepts
patient’s
health insurance
(or no team
Engage
members
of transition
insurance)
• Pre-transition communication between pediatric
and adult providers
• Adult clinic: assign youth contact person
• Case manager for youth
Basic Steps in Transitioning
Assess youth readiness & skills
Prepare youth for transition process
Engage members of transition team
Transfer care
Follow-up & evaluation
Basic Steps in Transitioning
•
•
•
•
Health summary or passport
Case conference
Transition team all aware of appointment
Transfer care
Release of information
Follow-up & evaluation
Basic Steps in Transitioning
• Verify that initial appointment kept
• For drop-outs, identify & enroll in support services
• Promptly reschedule appointment
• Reinforce need to transition
• Allow some safety net
Follow-up & evaluation
Transition Models
Pediatric
Clinic
Adult
Clinic
Pediatric
Clinic
Youth
Clinic
Adult
Clinic
Transition Models
Pediatric
Clinic
Youth
Provider
Adult
Clinic
Transition Models
Comprehensive
Center
(Pediatric, Adult, Family,
Women, etc)
Common Barriers to Successful
Transition
• Differences between pediatric & adult care culture
– Finding the right adult provider
– Adolescent communication skills
• Separation anxiety
– Youth, family
– Pediatric medical team
• Insurance lapses and non-reimbursable duplication of
services during the change
• Limited resources
– Inadequate time and resources in adult medicine practice
settings for young patients who may require extensive
psychosocial support
Common Barriers to Successful
Transition
•
•
•
•
Poor health literacy
Interim illness or pregnancy
Adult clinic waiting room
The rest of life’s stuff
– Moving away to college
– Financial instability
– Job or class schedule
Case 1
• Perinatal AIDS, in care at pediatric center since
birth
• Frequent illnesses
• Recent improvement in adherence
• Losing Medicaid
Case 2
• Recently infected MSM
• Estranged from family, living with older
partner
• Community college + part-time job
• Ongoing party life, substance use
• Bipolar disorder
Case 3
•
•
•
•
•
Young woman from rural area, infected age 13
On treatment, adherent
Covered by parent’s private health insurance
Ready for transition
Pregnancy test (+) at planned final visit
Summary of Transition Process
Assess youth readiness & skills
Prepare youth for transition process
Identify members of transition team
Transfer care
Follow-up & evaluation
• Individualize transition
plan based on patient
needs
• Begin the process early
• Patient needs to be
prepared
• Adult care provider
should actively be
involved
• Ensure that patient makes
it and stays
Applying the Model Locally
• Who are the adult providers in the area?
– HIV providers, OB-GYN
• Ryan White providers
• State Medicaid program
• Support services and ancillary providers
– Case management, housing, transportation,
mental health, dental
Transition Tools Available
• Transitioning HIV-infected Adolescents Into
Adult Care (New York State Department of
Health AIDS Institute: www.hivguidelines.org)
• Transitioning from Adolescent to Adult Care
(HRSA Care ACTION. June 2007. Available at:
ftp://ftp.hrsa.gov/hab/june2007.pdf)
• Adolescents Living With HIV (ALHIV) Toolkit
(http://www.k4health.org/toolkits/alhiv)
• http://gottransition.org