Health Transitions of Care Quarterly Learning Collaborative

The Health Transitions of Care (HTOC) learning collaborative, funded by RIDOH and Tufts Health Plan, met in March to share successes and barriers in improving care coordination for youth that are transitioning from pediatric to adult care. All HTOC cohort 2 practices successfully have identified and transferred 5 patients from pediatric to adult care and continue to engage patients in the transitions process. They have also improved upon the processes of communicating with their paired practice partner and incorporated the use of tacking tools and patient materials, such as a welcome letter. Preliminary patient survey data showed that 87.5% of young adults who have participated in the transitions process felt that it was explained in a way that they could understand and were given guidance about how their new provider approached accepting and partnering with patients. These practices have had great success in sustainability and spread: one practice is working within a system of care (RIPCPC) to take a system-wide approach to identifying tools and workflows that can be incorporated into electronic health records and identifying more teams that are interested in partnering together to do this work; the 2nd team (Hasbro/Center for Primary Care) has been able to increase resident participation in the transitions process. An additional 19 patients have been successfully transferred. Considerations for sustainability and spread were also discussed with recommendation that teams could be expanded to provide patients with more options around practice location,  gender of the adult provider, and practice acceptance of the patient’s insurance. The meeting recording can be viewed here and presentation slides here.