transition from adolescent to adult hiv care – practices & pitfalls
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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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
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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
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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 another2. Identify 3 barriers to successful transition3. Apply methods taught in the session to
circumstances in local health care settings
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Obtaining CME/CE Credits
• If you would like to receive continuing education credit for this activity, please visit:
http://www.pesge.com/RyanWhite2012
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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)
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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
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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
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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
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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
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Basic Steps in TransitioningAssess youth readiness & skills
Prepare youth for transition process
Engage members of transition team
Transfer care
Follow-up & evaluation
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Basic Steps in TransitioningAssess youth readiness & skills
Prepare youth for transition process
Engage members of transition team
Transfer care
Follow-up & evaluation
• Begin transition planning at least 3 years before expected transition, if possible• Transition checklist tools available• Review and modify the plan annually• Involve family, caregivers• Incorporate mental health assessments
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Basic Steps in Transitioning
Prepare youth for transition process
Engage members of transition team
Transfer care
Follow-up & evaluation
• Know when to seek medical care for symptoms or emergencies• Make, cancel, and reschedule appointments • Arrive to appointments on time • Call ahead of time for urgent visits • Request prescription refills correctly• Negotiate multiple providers and subspecialty visits • Understand health insurance, how to obtain it and renew it • Understand entitlements and know how to access them • Establish a good working relationship with a case manager
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Basic Steps in TransitioningAssess youth readiness & skills
Prepare youth for transition process
Engage members of transition team
Transfer care
Follow-up & evaluation
• Pediatric/adolescent care team should consider implementing a more structured appointment system before transition to promote skills building and to minimize “culture shock”• Policies are generally followed more strictly in adult care• Peer support groups • Skills practice sessions with medical students and residents
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Basic Steps in Transitioning
Engage members of transition team
•Multidisciplinary team•Pick the right adult provider•Accepts patient’s health insurance (or no insurance)•Pre-transition communication between pediatric and adult providers•Adult clinic: assign youth contact person•Case manager for youth
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Basic Steps in TransitioningAssess youth readiness & skills
Prepare youth for transition process
Engage members of transition team
Transfer care
Follow-up & evaluation
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Basic Steps in Transitioning
Transfer care
Follow-up & evaluation
•Health summary or passport•Case conference•Transition team all aware of appointment•Release of information
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Basic Steps in Transitioning
Follow-up & evaluation
•Verify that initial appointment kept•For drop-outs, identify & enroll in support services •Promptly reschedule appointment•Reinforce need to transition•Allow some safety net
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Transition Models
Pediatric Clinic
Adult Clinic
Pediatric Clinic
Youth Clinic
Adult Clinic
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Transition Models
Adult Clinic
Pediatric Clinic
Youth Provider
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Transition Models
Comprehensive Center
(Pediatric, Adult, Family, Women, etc)
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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
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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
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Case 1
• Perinatal AIDS, in care at pediatric center since birth
• Frequent illnesses• Recent improvement in adherence• Losing Medicaid
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Case 2
• Recently infected MSM• Estranged from family, living with older
partner• Community college + part-time job• Ongoing party life, substance use• Bipolar disorder
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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
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Summary of Transition Process• 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
Assess youth readiness & skills
Prepare youth for transition process
Identify members of transition team
Transfer care
Follow-up & evaluation
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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
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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