One ST3P Further: Optimizing Transition Care for Pediatric Sickle Cell Patients at Atrium Health

Introduction: This project explores opportunities to further enhance favorable outcomes of transitioning sickle cell patients from pediatric to adult care. Utilizing the ST3P-UP study as a foundation for transition care, persistent barriers to patient readiness were identified and solutions analyzed. Compliance issues and comfortability with adult clinic and staff were continued palpable barriers to successful transitioning. Atrium Health's sickle cell teams sought to better streamline the transition process to enhance patient preparedness and improve morbidity, mortality, and quality of life among this chronic disease population through a multidisciplinary approach. Opportunities to work alongside local community partners who strive to enhance health of the sickle cell population through their lifespan to refine transition care were explored. This multidisciplinary approach was trailed with focus to assemble a liaison for patients lost to follow-up.

Methods: A multidisciplinary QI team made up of pediatric, adult, and community-based organization (CBO) teammates convened using the Model for Improvement as the QI methodology. An aim statement and sFMEA were developed to guide the team’s work. Change ideas tested through multiple PDSA cycles included creating a structured connection between the patient and the adult team via the pediatric RN coordinator, a member of the adult team meeting the patient and delivering paperwork to the last pediatric appointment, initiating a monthly meeting between the pediatric, adult, and CBO teams to discuss the patients’ process of transitioning, and lastly the CBO contacting scheduled patients prior to their adult appointments to answer final questions, ensure transportation was available, and confirm the patient knew where to go for the appointment.

Results: Starting in February 2021, the team began to collect and analyze data on the percent of patients referred from the pediatric to the adult clinic, the percent of patients contacted by the adult clinic, the percent of patients scheduled for the adult appointment, and the percent of patients who attended their appointment with the adult clinic. Goals for patients to be referred and contacted were 90%. Goals for patients scheduled and attended adult appointments were 75%. All measures are meeting goals. When this improvement work started, a median of 50% of patients were being transitioned to the adult team by being seen for their first appointment. Currently, the data shows a median of 93% or 55 patients attending their first appointment with the adult team. The team continues to meet monthly to discuss the patients that need to be transitioned. The data is shared quarterly with a broader group including representatives from all contributing teams.

Conclusions: The multidisciplinary approach proved successful, yielding increased completed transition of sickle cell patients from the pediatric to adult clinic as defined by the team’s measures. The referral and first appointment scheduling process continues to prove efficient and reliable. Patients appear better versed in care plans/expectations and more comfortable with adult clinic and staff. Next steps will include patient feedback and measurement strategies to ensure these important coinciding factors are achieved.