Health Care Transition Quality Improvement Innovation at Henry Ford Health System
Got Transition continues to work with several large health systems (Henry Ford Health System, University of Rochester Medical Center, Cleveland Clinic, Walter Reed Medical Center, Children’s Mercy Hospital Kansas City) to implement the Six Core Elements of Health Care Transition. As part of our ongoing newsletter series, Got Transition interviews Dr. Tisa Johnson-Hooper (Medical Director, Center for Autism and Developmental Disabilities), who discusses the Henry Ford Health System’s (HFHS) implementation of the Six Core Elements. HFHS is a comprehensive, integrated, non-profit health care organization located in Metro Detroit, consisting of 30 health centers and 7 hospitals, averaging about 130,000 patient visits per year.

Q: Why is HFHS focusing special attention on health care transition?
A: HFHS is moving toward a population health and integrated care model. Consistent with national trends, HFHS has noted a gap in primary care among youth ages 17-22. Over 40% of these youth seen in HFHS pediatrics and family medicine primary care practices during their childhood years do not pursue continuous primary care with HFHS after the age of 18. Developing a process that engages and supports this patient population as they transition from a pediatric to an adult model of care is essential to achieve optimal health care outcomes. 

Q: What clinical process changes have you made to ensure that youth and young adults move from pediatric to adult health care?
A: We created a Health Care Transition Quality Improvement (QI) Team consisting of 2 pediatric and 2 adult practices for the purpose of customizing the Six Core Elements of Health Care Transition to coincide with the clinic processes in our health system. Thereafter, we piloted our customized tools within our primary care practices. Based on 3 years of work, we have integrated four Core Elements (transition policy, readiness assessment, transfer of care, and transfer completion) into the pilot clinical sites. We are currently in the process of disseminating the policy and readiness assessment throughout the entire health system.

Q: Have your changes shown any positive results for your system and patients?
A: We began a Meet & Greet pilot 9 months ago. This pilot assesses the integration of both pediatric and adult core elements related to transfer of care and transfer completion into our clinical practices. The Meet & Greet pilot is a comprehensive referral system from pediatric to adult medicine. The process begins in pediatrics, encompasses a bridge period of time when specific electronic information and resources are provided to the patient, and ends with an appointment in adult medicine. Initial patient satisfaction surveys have been overwhelmingly positive. Specifically, youth are communicating that they feel more knowledgeable about their health and are prepared to transition to adult medicine.

Q: What are the main lessons learned from this work?
A: The main lesson learned regarding integration of the Six Core Elements into a large health system with an established electronic medical record, like Henry Ford, is to be patient. Once tools have been customized, going through the required institutional committees, boards, and IT reviews can be lengthy and trying. However, each step serves a valuable purpose and ultimately facilitates successful and sustaining implementation.