Abstract: TH-PO771
A Young Adult Nephrology Transition Clinic: A Successful Model
Session Information
- Pediatric CKD
November 07, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Pediatric Nephrology
- 1700 Pediatric Nephrology
Authors
- Nishi, Laura, Northwestern Medicine, Chicago, Illinois, United States
- Langman, Craig B., Northwestern University- Feinberg School of Medicine , Chicago, Illinois, United States
- Ghossein, Cybele, Northwestern University- Feinberg School of Medicine , Chicago, Illinois, United States
Background
Survival of pediatric patients with chronic disease has increased leading to a greater number of patients transitioning from pediatric to adult care. A formal pediatric to adult transition process is important in improving medical adherence in these young adults. Despite this, few adult nephrology centers have transition protocols in place. To address this, we implemented a combined nephrology transition of care program at Lurie Children’s Hospital (LCH) and Northwestern Medicine (NM). Here we present our 5 year data.
Methods
The pediatric team identified transfer patients and communicated with the adult team, a nephrologist, PA and social worker, about patient history and potential obstacles to successful transition. The initial appointment occurred at LCH with subsequent visits at NM. During all visits, patients had one on one time with each of the providers. Monthly reviews were conducted to determine if proper follow up had occurred and if not, procedures of enhanced follow up including phone calls and email were implemented.
Results
A total of 84 patients were seen with the results outlined in Table 1. Successful transition was defined as at least one follow up visit in the adult clinic. 40% of patients required enhanced follow up. 21% of patients either unsuccessfully transitioned or had delayed drop out, defined as lost to follow up after a successful transition.
Conclusion
Based on our five year experience, transition of care from pediatric to adult nephrology providers can be successfully facilitated with a protocol driven model that includes engagement of adult and pediatric teams. This patient group, however, is still at high risk of being lost to follow up.
Table 1: Patient outcomes.
Outcome | Transition Program Particpants (n=84) |
Successful Transition One visit Two visits Three + visits | 65 (78%) 13 (15%) 15 (18%) 37 (44%) |
Unsuccessful Transition | 6 (7%) |
Delayed Drop Out | 12 (14%) |
Pending Follow Up | 7 (8%) |
Un enrolled | 6 (7%) |
Figure 1: Follow up as a function of transition year.