Reports From the Field

Transition Readiness Assessment for Sickle Cell Patients: A Quality Improvement Project

Journal of Clinical Outcomes Management. 2014 June;21(6)

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Cycle 3

Following a few months using the assessment process, each member of the team provided feedback about their observations from the second cycle. The third cycle of the PDSA addressed some of the barriers identified in Cycle 2 by adding the POA and timeline for reassessment. With this information, the nurse case manager was able to identify and contact families who had significant gaps in the learning curriculum. Additionally, services such as psychological testing were scheduled in a timely manner to address academic problems and to provide rationale for accommodations and academic/vocational services before patients transferred care to the adult provider. With the number of assessed patients increasing, it was determined that a reliable tracking system to monitor progress was essential. Thus, a transition database was created to document the domain scores, individualized plan of action, and other components of the transition program, such as medical literacy quiz scores, completion of pre-transfer visits to adult providers, and completion of the PHR. During this cycle, 20 patients were assessed out of a total of 22 eligible patients (90.9%); 2 patients were lost to follow-up.

Cycle 4

This cycle is currently underway and comprises monthly assessments of eligible 17-year-old patients with SCD. From January 2013 to May 2013 we have assessed 100% of the eligible patients (21/21). All information obtained through the assessment tool is added to the transition database. Future adjustments and modifications are planned for this tool as we continue to evaluate its impact and value.

Discussion

The transition readiness assessment tool was developed to evaluate adolescent patients with SCD aged 17 years regarding their progress in the transition program and level of transition readiness. Most transition readiness measures available in the literature consider the patient and parent perspective but do not include the health care provider perspective or determine if the patient received the information necessary for successful transition. Our readiness assessment tool has been helpful in providing a structured and quantifiable means to identify at-risk patients and families prior to the transfer of care and revealing important gaps in transition planning. It also provides information in a timely manner about points of intervention to ensure patients receive adequate preparation and services (eg, psychological/neuropsychological testing). Additionally, monthly meetings are held during which the tool is scored and discussed, providing an opportunity for members of the transition team to examine patients’ progress toward transition readiness. Finally, completing an individualized tool in a multidisciplinary setting has the added benefit of encouraging increased staff collaboration and creating a venue for ongoing re-evaluation of the QI process.

We achieved our objective of completing the assessment tool for 80% of eligible patients throughout the cycles. The majority of our nonassessed patients was lost to follow-up and had not had a clinic visit in 2 to 3 years. Implementing the tool has provided us with an additional mechanism to verify transition eligibility and has afforded the transition program a systematic way to screen and track patients who are approaching the age of transition and who may have not been seen for an extended period of time. As with any large program following children with special health care and complex needs, the large volume of patients and their complexity may pose a challenge to the program, therefore having an additional tracking system in place may help mitigate possible losses to follow-up. In fact, since the implementation of tool, our team has been able to contact families and in some cases have reinstated services. As a by-product of tool implementation, we have implemented new policies to prevent extended losses to follow-up and patient attrition.