Background/Purpose: Patients with pediatric rheumatologic diseases live well into adulthood, necessitating transition from pediatric to adult medical providers. GotTransition.org details 6 core elements clinicians can implement to create effective transition: policy, registry, readiness, planning, transfer and completion.

Methods: The core elements were used to design a transition pathway. A transition policy was created, and a patient registry constructed. Provider-led education on readiness and planning were structured during clinic visits using an electronic medical record-based tool. Patient self-reported transition readiness was assessed with a patient-administered survey, the ADAPT (Adolescent Assessment of Preparation for Transition). All rheumatology providers gave input through monthly transition meetings. Provider participation was encouraged through Maintenance of Certification points.

Results: The transition policy was acknowledged and signed by 33 patients during a pilot release. 481 return patients age 14-19 years were identified by review of clinic schedules and added to the transition registry. ADAPT surveys were completed by 101 patients. Most respondents were 15-18 years of age (79%), female (70%), and Caucasian (77%); 41% were Hispanic. 28% had juvenile arthritis and 18% had lupus. Most patients had private insurance (59%) or Medicaid/Children’s Health Insurance Program (36%). Not unexpectedly, ADAPT scores increased with age, and older adolescents (18-19 years) achieved the highest averages: counseling in transition self-management (58/100) and prescription medications (93/100), and in transfer planning (33/100). All patients had scores >50/100 for medications. There was no significant difference in survey results with respect to diagnosis or age at diagnosis. Since the project began, 25 high-risk patients, average age 19.4 years, have transferred into an on-site transition clinic. Transitioned patients attended their first adult appointment an average of 3.2 months from their last pediatric appointment, and only 11% required hospitalization within the first year after transition.

Conclusion: Effective healthcare transitions are critical to the wellbeing of patients with childhood-onset rheumatologic conditions. The creation of a transition pathway in rheumatology clinic has been well received by patients and providers. We have demonstrated good scores for counseling in medications and identified a need to improve self-management and planning counseling. Future directions will include 1) formalizing the final 2 elements of the pathway for all transitioning patients, including standardizing a transition letter to the adult rheumatology provider, and 2) further assessing outcomes. Our ultimate goal is to create a sustainable and successful BRIDGE between pediatric and adult rheumatology care.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/baylor-rheumatology-initiative-developing-and-guiding-engagement-bridge-transition-pathway-creation-and-implementation/