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P-147 YI A Retrospective Look at an IBD Transition Initiative

BACKGROUND:To develop a specific model and plan to successfully transition care of the adult IBD patient, a multidisciplinary task force from Cincinnati Children's Hospital Medical Center (CCHMC) and the University of Cincinnati Hospital (UC Health) began meeting in 2010. The Transition of Care Initiative was developed and implemented at CCHMC in early 2012. METHODS:IBD patients, 16 years and older, were identified for preparation to transition during weekly multi-disciplinary pre-clinic planning meetings. The transition coordinator, a social worker, would meet with patients in the clinic for self-management skills assessment and goal setting over subsequent visits. Once readiness was determined by the patient, family and medical team, the transfer process was implemented. This began with the patient receiving the UC Health Welcome Packet which included information on the adult IBD providers, office locations and contact information. A clinical summary was written and pertinent medical records were obtained and sent to the UC Health transition coordinator. Records were then reviewed, triaged to the appropriate adult provider and the first visit was arranged which included a tour of the facility. RESULTS:Of the 18 patients transitioned to UC Health between 2012 and 2014, 10 males and 8 females, 4 patients had no record of scheduling an initial appointment, 2 with documentation of initial transfer with no subsequent follow up, 2 are deceased and 1 relocated out of the area following transition. Of the remaining 9 patients, 6 are compliant with follow up appointments, adherent to medications, laboratory testing and surveillance. Five of these patients have quiescent disease and 1 is in a documented flare. Three patients are considered non-compliant, 2 with quiescent disease and 1 with a documented flare. Two patients initially presented in a flare requiring hospital admission, 1 was lost to follow up and 1 is considered compliant and is currently regaining remission. CONCLUSIONS:The collaboration between CCHMC and UC Health for the IBD Transition of Care Initiative has paved the way for increasing the number of patients successfully transferred to adult care. As part of the evaluation phase, several key learnings were identified. UC Health determined adjusting clinic scheduling practices to accommodate the needs of the transitioning patient may be in order, including less harsh consequences for being late or missing an appointment during the transition period since patients are adjusting to a new medical home. UC Health identified the need to enhance ancillary support services to better approximate services provided in the pediatric setting such as assistance with transportation, psychiatric/psychology referrals and pain management referrals. CCHMC determined the pediatric team's role at the time of transition becomes that of a coach to the transitioning patient and family, ensuring timely and appropriate communication with the adult care team and to provide telephone support for the adult team with the goal of promoting positive encounters in the adult setting. Transitioning patients in a planned, multi-disciplinary approach can optimize patient's success in the adult medical care model.