Giving the Green Light for Transfer to Adult Care: One Center's Interdisciplinary Approach

Background:

Many strides have been made in the transition of care from pediatrics to adult care for patients with sickle cell disease.¹ Understandably, efforts have been made to garner feedback from patients to determine which issues are important to them to address during this vulnerable time in their lives full of change. With the integration of the six core elements of Health Care Transition including (1) transition policy, (2) tracking and monitoring progress, (3) assessing transition readiness, (4) planning for adult care, (5) transferring to adult care, and (6) integrating into adult care, much focus has been put on the preparation and transfer of care process of adolescents with sickle cell disease. ² Little has been shared, however, about the specific timepoint when the patient is cleared for transfer and the process involved in this ultimate endorsement for clearance. In acknowledging their haphazard green light process, one pediatric team created a new protocol to make the ultimate clearance of transition-aged patients an interdisciplinary affair.

Methodology:

Interdisciplinary providers agreed to take part in a clearance consult for transition-aged patients to assess their readiness for transfer of care to the adult clinic. Chaplaincy, pharmacy, psychology, social work, and medical providers prepared individual curriculums, assessments, and education for review. A monthly calendar was created to show interdisciplinary providers when eligible patients would be coming to the clinic and a tracking template was included as a SMART phrase in EPIC. In-basket messages were sent as reminders for providers to conduct their clearance consults if possible. Each provider documented in the template when their clearance assessment was completed and noted any barriers to transfer if identified.

Results

At the time of submission, five patients have been cleared via this new multidisciplinary protocol. Through this process, providers have voiced a feeling of shared responsibility and camaraderie feeling more of an equal contributor to patient preparedness. Instead of team members wondering if the patient is ready or when they are going to transfer, this standardized process is helping improve team care coordination and communication. The ultimate decision-making has been made to be one anchored in the biopsychosocial model of care as opposed to solely the biological medically oriented one. Patients have received education regarding their physical, mental, emotional, spiritual, and pharmaceutical health as opposed to just a few topics via a few disciplines. P-D-S-A cycles have helped the team pivot from overwhelming in-basket emails to the whole team to monthly reviews of the clinic calendar and individual reminders instead.

Conclusions

Making the clearance process a standardized protocol has benefits for the team and patient. In spreading responsibility among team members, they can contribute their expertise and support to the patient transfer while making that final call less overwhelming and confusing for other colleagues. This is a solid step in helping to move from a medically dictated transition model to a more holistic team and patient-centered approach.

Raj:Sanofi: Consultancy; Jazz: Speakers Bureau; US world meds: Consultancy; Pfizer: Honoraria, Speakers Bureau.