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Strengthening the evidence base for maternal and child health programs

New: MCH Best strategies database for sample ESMs

Evidence Tools
MCH Best. NPM 12: Health Care Transition

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Strategy. Six Core Elements Adaptation with Quality Improvement (QI)

Approach. Incorporate the Six Core Elements™ in a learning collaborative or medical center/hospital system with built-in QI activities.

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Overview. Current research has shown that adaptation of the Six Core Elements of Health Care Transition (HCT 3.0)1 in practice (including written plan and other services) may improve transition.2 The Six Core Elements of Health Care Transition is a structured process that encompasses transition planning, transfer of care, and integration into adult care that can be customized and applied in a variety of different pediatric and adult health care settings and programs.3

Encourage use of Six Core Elements of HCT 3.0 in:

There are several methods to accomplish this:

Evidence. Moderate Evidence. Having a structured health care transition process in place for youth with special health care needs is associated with significant positive outcomes related to population health, consumer experience, and service utilization. Access the peer-reviewed evidence through Outcome Evidence for Structured Pediatric to Adult Health Care Transition Interventions: A Systematic Review and Outcomes of pediatric to adult health care transition interventions: An updated systematic review (Got Transition®/Center for Health Care Transition Improvement).  The American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians call for the use of the Six Core Elements in their 2018 Clinical Report. (Access the Clinical Report, Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home at Got Transition). (Read more about understanding evidence ratings).

Target Audience. Health care practices/clinics/systems, care coordination programs, managed care organizations, public health programs.

Outcome. Can be measured in several ways -- self-care knowledge/skills, adherence to care, disease-specific measures, clinician experience with transition process, time between last pediatric and initial adult visit, preventive/ambulatory care visits in adult settings, emergency room visits, hospital use, and costs of care.

Examples from the Field. There are currently 13 ESMs across all states/jurisdictions that use this strategy directly or intervention components that align with this strategy. Access descriptions of these ESMs through the MCH Digital Library. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Using the approach “Incorporate the Six Core Elements of Health Care TransitionTM in a learning collaborative or medical center/hospital system with built-in QI activities,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies):

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of clinics/systems adapting the Six Core Elements.
  • Number of transition-aged youth receiving all of the Six Core Elements.
  • Total score from Current Assessment of HCT Activities in clinic/system.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percentage of clinics/systems adapting the Six Core Elements.
  • Percentage of transition-aged youth receiving all of the Six Core Elements.
  • Percentage of clinics/systems whose total score increased from Current Assessment of Health Care Transition Activities.
  • Percent of transitioning youth reporting positive overall health care transition experience.

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of adolescents attending clinics/systems adapting the Six Core Elements who report increased knowledge and skills in the components of health care transition after taking a short evaluation of the program.
  • Number of youth with special health care needs who made initial adult appointment within 6 months of last pediatric visit.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percentage of youth with special health care needs who made initial adult appointment within 6 months of last pediatric visit.
  • Percentage of adolescents attending clinics/systems adapting the Six Core Elements who report successful health care transition.

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4).

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


Note and Reference:

1 The Six Core Elements include: (1) transition policy, (2) transition tracking and monitoring, (3) transition readiness, (4) transition planning, (5) transfer of care, and (6) transfer completion.

2 White PH, Cooley WC, Transitions Clinical Report Authoring Group, American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics. 2018;142(5):e20182587

10 peer-reviewed articles have documented progress in implementing a structured transition process using the Six Core Elements of HCT in quality improvement pilots:

1. A Program of Transition to Adult Care for Sick Cell Disease by Saulsberry et al 2019
2. Evaluation of a health care transition improvement process in seven large health care systems by Jones et al 2019 
3. Implementing a Structured Health Care Transition (HCT) Process for Sickle Cell Disease (SCD) Using Quality Improvement: Early Results of a SCD HCT Learning Collaborative by Osunkwo et al 2019 
4. Perceptions of Health Care Transition Care Coordination in Patients With Chronic Illness by Lemke et al 2018
5. Using Quality Improvement in Resident Education to Improve Transition Care by Volertas et al 2017
6. Transfer from Pediatric to Adult Endocrinology by Jones et al 2017
7. Pediatric to Adult Transition: A Quality Improvement Model for Primary Care by McManus et al 2015
8. Incorporating the Six Core Elements of Health Care Transition Into a Medicaid Managed Care Plan: Lessons Learned From a Pilot Project by McManus et al 2015
9. 2013 article on the HCT Learning Collaborative in DC [Could not locate]
10. Health care transition in School-Based Health Centers: A Pilot Study by White et al 2020 (in review)

3 Got Transition is now offering the updated Six Core Elements of Health Care Transition™ 3.0, which define the basic components of HCT support. The Six Core Elements 3.0 are intended for use by pediatric, family medicine, med-peds, and internal medicine practices.To help practices transform their HCT processes, Got Transition has also developed new practical step-by-step Implementation Guides dedicated to each core element. Got Transition offers background information on how to use the Implementation Guides, as well as a Quality Improvement Primer for those unfamiliar with the QI process. Guides and information are available at www.GotTransition.org/Implementation.


 

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.