Elsevier

Journal of Pediatric Nursing

Volume 30, Issue 5, September–October 2015, Pages 700-713
Journal of Pediatric Nursing

Incorporating the Six Core Elements of Health Care Transition Into a Medicaid Managed Care Plan: Lessons Learned From a Pilot Project

https://doi.org/10.1016/j.pedn.2015.05.029Get rights and content

Highlights

  • The Six Core Elements were effectively customized for use in a Medicaid health plan.

  • Completion of transition elements was high among plan's young adult pilot group.

  • Most young adults were unprepared to manage their own care.

  • Transfer of care was most difficult and required extensive care manager outreach.

  • Starting transition planning before age 18 is essential.

This pediatric-to-adult health care transition pilot project describes the process and results of incorporating the “Six Core Elements of Health Care Transition (2.0)" into a Medicaid managed care plan with a group of 35 18–23 year olds who have chronic mental health, developmental, and complex medical conditions. The pilot project demonstrated an effective approach for customizing and delivering recommended transition services. At the start of the 18-month project, the Medicaid plan was at the basic level (1) of transition implementation of the Six Core Elements with no transition policy, member transition readiness assessment results, health care transition plans of care, updated medical summaries, transfer package for the adult-focused provider, and assurance of transfer completion and consumer feedback. At the conclusion of the pilot project, the plan scored at level 3 on each core element. The primary reason for not scoring at the highest level (4) was because the transition elements have not been incorporated into services for all enrollees within the plan. Future efforts in managed care will benefit from starting the transition process much earlier (ages 12–14), expanding the role of nurse care managers and participating pediatric and adult-focused clinicians in transition, and offering payment incentives to clinicians to implement the Six Core Elements of Health Care Transition.

Section snippets

Project Design

This transition pilot project took place over 18 months, with the first 9 months focused on customizing the Six Core Elements with plan officials and recruiting pediatric and adult practices and HSCSN enrollees. The final 9 months were devoted to piloting the new transition process and tools with a group of 35 young adult enrollees with chronic conditions and evaluating the results in terms of changes in HSCSN's transition process and in the pilot groups' receipt of recommended transition core

Design Elements: Customizing the Six Core Elements for HSCSN's Pilot Project

Following a review of HSCSN's care plan template and their insurance transition process, the project team initiated a thorough examination of the sample tools from the Six Core Elements. The team concluded that the transition policy and transition care plan were the only 2 elements that needed to be significantly modified for the pilot project. As shown in Figure 1, HSCSN's new transition policy was customized to be similar to the plan's insurance transition policy—written as a question

Discussion

The results of this first-of-its-kind transition project reveal that the Six Core Elements of Health Care Transition can be customized and incorporated for use by care managers within a managed care plan in a short time frame. At the start of the project, HSCSN was at the basic level of transition implementation with respect to not having a health care transition policy, tracking members' transition progress, incorporating transition readiness into members' plans of care, identifying interested

Implications for Practice

This project highlights several implications for practice, especially for nursing practice, given their key role as care managers in managed care plans and also in clinical care (Betz, 2007). Managed care leadership support was an essential feature of this transition project. HSCSN's vice president for care management, a registered nurse, participated in all aspects of the transition project design, implementation, and evaluation of the project with the support of the chief operating officer

Limitations

There are several limitations to this transition study. The small sample size of the pilot group and the participating pediatric and adult-focused providers limit the study's generalizability. Since the study results are only based on those who agreed to take part in the transition pilot, sampling bias is another methodological limit. In addition, implementation of the pilot study was not completed at the time that this article was submitted; however, the majority of the pilot project results

Funding

This work has been supported by a grant to The National Alliance to Advance Adolescent Health from the DC Department of Health (CHA.PSMB.NAAAH.052013). The authors have no financial relationships relevant to this article to disclose or conflicts of interest to disclose.

Acknowledgements

The authors acknowledge the encouragement from Margaret Copemann, project officer from the District of Columbia's Department of Health. We also appreciate the leadership support from HSCSN, including Danny Bellamy, Dr. Rhonique Harris, Robyn Meredith, and Abigail Brooks. Finally, we gratefully acknowledge the involvement of Drs. Kermit Simrel, Marcee White, Yousef Dawood, Gloria Wilder, and Asha Robinson-Parks for their willingness to participate in this project.

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