Annotation: This is a five-part Webinar Series featuring examples of best practices among state Title V agencies, tools and resources, and problem-solving strategies. Titles include: (1) Starting A Transition Improvement Process Using the Six Core Elements of Health Care Transition; (2) Transition Preparation; (3) Transfer to Adult Care; (4) Integration into Adult Care; and (5) Youth, Young Adult & Parent Engagement. Recordings and handouts are available.
Learning Objectives: Session 1:
• Overview of health care transition baseline results from Title V care coordination (CC) programs.
• Forming a HCT quality improvement team with CC team and youth/young adults/parents.
• Defining HCT pilot population, timeline, measures of success.
• Selecting HCT core elements and delineating roles of CC program and YSHCN providers.
• Identifying key components of HCT policy for CC programs that families/youth want to know.
• Customizing transition readiness assessment (RA) for CC programs
• Piloting and disseminating HCT policy and RA.
• Incorporating RA skill needs into plan of care and educating youth and families on needed skills.
• Preparing medical summary and emergency care plan with youth and families and their providers.
• Identifying willing adult primary and specialty providers.
• Sequencing plans for transferring young adults with multiple providers.
• Identifying ways to support adult practices (consultation, care coordination).
• Preparing transfer package and communicating with pediatric and adult practices.
• Ensuring welcome and orientation FAQs from the adult practice to transferring young adults and pediatric practice.
• Facilitating initial appointment to adult doctor, including confirmation of receipt of transfer package.
• Supporting adult practice with CC assistance from Title V and linking to adult disability resources.
• Identifying youth/young adults/parents to participate in HCT initiatives in Title V CC programs.
• Providing transition education and training and mentoring opportunities.
• Eliciting consumer feedback with HCT care coordination process.
• Building youth/young adult/parent leadership roles on HCT within state Title V programs.