Partners with HRTW:

Improving Transition Outcomes

Brief History

• CHOICES - 1990-1999– Build strong interagency partnerships across

public and private systems of care for children and youth with special health care needs

– Improve systems for coordination of care in both Shriners Hospitals and State Title V CSHCN programs

– Integrate transition into the mission to improve interagency partnerships and care coordination

Brief History

• CHOICES - 1990-1993: – KY, SC, OH and TN were involved in collaboration activities –

3 states with Shriners Hospitals and TN without

• CHOICES - 1994-1996: – Project responded to MCHB and SHC requests to expand

focus of interagency collaboration to include Vocational Rehabilitation

– Title V Care Coordinator at Shriners Hospital: FL, IL, KY, MN, MO, OH, OR, SC, UT, WA

• CHOICES - 1996-1999

– Joined the HRTW projects and served as platform for a series of three national conferences on transition

• Washington, DC, Chicago, Charleston, SC

– 4 state/hospital demonstration projects • KY, UT, FL, and HI

Brief History

• KY TEACH - 2000-2003– Partnered with this HRTW demonstration project at

state/hospital level in Kentucky to change practice within one state and hospital

• HRTW National Centers - 2002-2010– Collaborated with HRTW National Centers to integrate

what had been learned from HRTW demonstration projects into best transition practices across 21 Shriners Hospitals

Brief History

Outcomes: Clinical Guidelines

• Clinical Guidelines developed and adopted across the system regarding recommended best transition practices

• Tools and resources shared across hospital system and on HRTW web site

• Focus on improving transition services for both individuals and populations

Clinical Guidelines

• Focus on developmental touch points– Starting early– Providing developmentally appropriate education and

referral to resources (infancy, early childhood, entry into elementary, middle and high school)

– Tracking progress over time– Coordinating care throughout the transition years

beginning at age 14– Focus on appropriate referral and hand off to adult health

care

Outcomes: Special Programs

• Transition camps• Week-end events/resource fairs• Proms• Sporting events• Teen support groups• Work programs• Learning independent living skills

Outcomes

• Focus on quality improvement and outcomes– Exit survey

• What was delivered – Information– Education– Referral

– Post graduation follow-up survey• How are our youth doing following discharge?• What could we have done better?

Next Steps

• Improving electronic documentation• Developing Free-Mind system for organizing

transition resources and making available to interested hospitals

• Expanding quality improvement and outcomes evaluation activities across all hospitals

• Continuing to encourage strong interagency partnerships and improved care coordination focused on improving transition outcomes

Contact Information

• Betty Presler– bpresler@shrinenet.org– 859-268-5744– Shriners Hospitals for Children

1900 Richmond Road

Lexington, Kentucky 40502