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Step 4: Formalize the Process and Sustain Change
Once you establish a successful strategy for integrating Youth Health Transition (YHT) services into your clinic workflow, you can formalize the process to ensure consistency across all patients. Without sustainability, valuable time and resources are wasted investing in organizational improvement.
Due to the high level of variability in health care, quality improvement must be continuously integrated into an organization's culture to provide high-quality care and reliable safe practices. Remember to recognize and celebrate successes along the way - it is important for implementation and long-term sustainability.
Goal:
The goal of this step is to determine what works best in order to establish a system that allows you to successfully integrate and sustain YHT services into your workflow.
1. Create a Clinic Policy
After a few months of fully implementing your priority tasks, create a YHT clinic policy.
A written youth transition policy can serve as a useful education tool for both staff and patients and help establish consistent service delivery.
Use the Sample Transition Policy as an example for writing one for your clinic. The policy should include the following:
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The age transition services begin at your practice (typically between 12-14 years old)
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The expected age of transfer to adult services (typically between 18-22 years old)
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The transition services your clinic offers (helping to identify an adult provider, sending medical records, communicating with the new adult provider about the unique needs of your patients)
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The adolescent and young adult's role in transition and managing their health and health care (scheduling appointments, understanding their insurance)
2. Integrate Youth Health Transition Services into Your Clinic’s Electronic Health Record (EHR)
Fully integrating YHT services into your clinic’s EHR will make it easier to ensure consistency and track data. Establishing standardized documentation for transition services will help minimize service redundancy. Document topics covered at each visit to cue topics for subsequent visits.
The EHR case management module may be useful for documenting transition referral coordination and follow-up. We also suggest using screenings and assessments to guide any anticipatory guidance you provide.
Look for overlap between recommended transition services and existing quality measures (HEDIS, PCMH, Child Core Measures) reported by the clinic.
If the clinic EHR includes an age-specific encounter screen for documentation of adolescent health assessments, review the assessment screen for transition service items and explore the social history section for items related to the social determinants of health. Items to look for include:
- Self-care management
- Insurance Maintenance
- Education/vocation
- Health promotion/exercise
- Nutrition/food security
- Safety/risk assessments
- Sexual Health
- Depression/mental health
- Dental/oral health
- Independent living support
- Adult provider referrals/transfers
- Age of majority – privacy laws
If your practice’s EHR system supports an online patient portal, consider using it to relay supplemental information.
An online patient portal can be used as an important communication channel for transition-aged youth, as adolescents and young adults often prefer electronic communication.
See the Readiness Assessment Checklist and Project Planning Worksheet.
3. Use CPT Codes for Reimbursement
A major benefit to implementing YHT services into a clinic’s regular practice is that they are reimbursable.
The latest version of the American Academy of Pediatrics Coding and Reimbursement Tip Sheet for Transition from Pediatric to Adult Health Care includes a list of transition‐related CPT codes, corresponding fees, and relative value units (RVUs).
The tip sheet also includes a set of clinical vignettes with recommended coding for transition-related services to help you understand which codes to use and when. See an example on the next page and find the latest version of this document at GotTransition.org under “Resources” --> “Payment and Transition”.
Note: For Louisiana Medicaid patients, some YHT services are bundled into the EPSDT adolescent well-care visit.
Need Help?
Our experts can provide technical assistance to you through this process. Fill out the Implementation Training and Support Request Form and contact us at BFH-FamilyResourceCenter@la.gov or 504-568-3405 for more information.