Getting the balance right helena gleeson
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Transcript of Getting the balance right helena gleeson
Getting the Balance Right Adult Services Role in improving Transition
Helena GleesonLeicester Royal Infirmary
Representing RCP YAASG
What we know….
• Young people get lost to follow up around the time of transfer and suffer a deterioration in their health
• Young people are dissatisfied with current provision of care during transitionWhose fault is it?
Current health service
Paediatric services and paediatricians
Adult services and adult physicians
Primary Care and General Practitioners
Definition of Transition
"A purposeful, planned process that addresses the medical, psychosocial and
educational/vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from child
centred to adult-oriented health care systems"
(Society of Adolescent Medicine 2003)
Where is the
responsibility?
Suggestion
“Paediatric and adult health care professionals need to provide developmentally appropriate health care for adolescents and young adults
with long term physical and medical conditions addressing medical, psychosocial and educational/vocational needs working
together when necessary to support continuity of care“
Emerging Adulthood
Emerging Adulthood 18-23 years Identity development in adolescence Identity exploration in emerging adulthood
JJ Arnett 2000Emerging adults vs adultsSimilar logical competenciesBUTDifferent social and emotional factorsDifferences in decision and risk taking
Developmental Delay in Young Adulthood
• Significantly delayed milestones (autonomy, psychosexual and social development) in young adult survivors of childhood cancer and end stage renal disease
Stam H et al, 2006
• Missed adolescent milestones (psychosocial and vocational) in young adults with congenital heart disease
Lyon M et al, 2006
• Similar rates BUT DELAYED in adolescents with CF and sickle cell compared to healthy peers
Britto MT, 1998
Suggestion
“Paediatric and adult health care professionals need to provide developmentally appropriate health care for adolescents and young adults
with long term physical and medical conditions addressing medical, psychosocial and
educational/vocational needs working together when necessary to support continuity
of care“
UNICEF REPORT CARD 11, 2013
10% NEET24th in the
league table
Adolescent data 2011
Suggestion
“Paediatric and adult health care professionals need to provide developmentally appropriate health care for adolescents and young adults with chronic physical and medical conditions
addressing medical, psychosocial and educational/vocational needs working together when necessary to support
continuity“
Continuity Description
Relational A therapeutic relationship with a named health professional
Longitudinal Care from as few professionals as possible, consistent with needs
Management Continuity of diabetes management through a common purpose and plan
Cultural Seamless progression from a child to adult service culture across service interfaces
Flexible Adjustment to the needs of an individual over time
Developmental Care which grows with the changing demands of the client group and works to facilitate that change
Informational and/orCross boundary
Excellent information transfer following the service user including effective communication between professionals and services
Smooth transition
DM-related hospitalization rates increased from 7.6 to 9.5 cases per 100 patient-years in the 2 years after transition to adult care (P .03).
Previous DM-related hospitalizations,lower incomefemale genderliving in areas with low physician supply
With controlling for all other factorsIndividuals with continuity of care were 77% less likely to be hospitalised than those with lack of continuity
Suggestion
“Paediatric and adult health care professionals need to provide developmentally appropriate health care for adolescents and young adults with chronic physical and medical conditions
addressing medical, psychosocial and educational/vocational needs working together when necessary to support
continuity“
Don’t forget young people presenting in late adolescence or
young adulthood
Adult services are well aware of the importance of age appropriate care
Basic care for elderly 'lacking' BBC News - 10 hours agoBasic care for the elderly in hospitals and care homes in England is still not good
enough, the regulator says. The Care Quality Commission report, based on a snapshot of services, found about a third failed to meet all the standards for nutrition and dignity.
More hospitals are failing to treat their patients with dignity: Fifth don't meet ... Daily Mail - 14 hours agoRising numbers of hospitals are failing to respect the dignity and privacy of patients,
the care watchdog warns. Nearly a fifth don't meet national standards for ensuring patients – many of them elderly – are treated with proper compassion and consideration.
Elderly still suffer from lack of basic care Public Service - 4 hours agoAround 20 per cent of NHS hospitals and care homes failed to treat elderly patients
with dignity in 2012 and privacy was not as well respected as it was in 2011, according to the Care Quality Commission (CQC). Reporting on inspections that took place last ...
YP health should also be way up the agenda and in the media
• Domain 1 - prevent young people from dying prematurely
• Domain 2 - enhance the quality of life for young people with long term conditions
• Domain 4 - ensure young people have a positive experience
• Domain 5 - allow young people to be treated and cared for in a safe environment and protecting them for unavoidable arm
YP health should be way up the agenda
• Domain 1 - prevent young people from dying prematurely
• Domain 2 - enhance the quality of life for young people with long term conditions
• Domain 4 - ensure young people have a positive experience
• Domain 5 - allow young people to be treated and cared for in a safe environment and protecting them for unavoidable arm
80.7% of 16–24 year olds vs 89.2% of older adults report good care (Emergency Department Survey 2008)
86.5% of 16–24 year olds vs 92.7% of older adults reported good care (Inpatient Survey 2009)
Getting the Balance Right
RCPYoung Adult and Adolescent Steering Group
• Chaired by Dr Angela Robinson (Consultant GU Medicine)
• Last meeting representation from 12 specialist societies
• Training • Clinical governance, standards, and aspects of service
delivery• Young person involvement
• Acute admissions the most difficult/negative aspect of transferring from paediatrics
• Lack of information/preparation prior to inpatient episode– not covered in transition preparation/planning– expectations based on experiences in children’s wards
• parents present 24/7 vs visiting hours only• health and mental conditions of other patients
• Young adults / their conditions: ‘unusual’ patient group– lack of knowledge/understanding of condition
• self-care needs• parental involvement in information sharing/decision-
making
‘Young adults’ as adult health service users: being an inpatient
28Bryony Beresford, The STEPP Project
Unnecessary Deaths!
• Top doctor quits over death of his patient at Salford Royal Hospital
• 28 Jul 2011 12:17 Top doctor admitted he had ‘failed’ Mark Holland, who suffered two heart attacks while being treated in Salford Royal Hospital. Mark, 24, had a rare metabolic disorder and needed a special diet and liquids. But a five-day inquest heard he had no treatment management plan, monitoring of his heart was ‘indequate,’ and suggestions by his family about how to look after him were ignored.
Type of admission by age UHL Data
11 to 15 16 to 19 20 to 240
2000
4000
6000
8000
10000
12000
ChildrensWomensSurgeryMedicine
Core Medical Trainee Pilot Questionnaire
• 59% no specific training/teaching in adolescent health but even of those that said they had teaching 71% said it was minimal
• 100% of CMTs had regular exposure to young people
• AMU was the commonest place for this to happen.
• Reason for admission – 53% DSH plus or minus intoxication– 65% chronic conditions (T1DM, Crohns)
Scenario – 16 year old admitted with D&V with evidence of self harming
compared with older people how competent/confident do you feel
Less competent/confident
In your ability to help the patient with self management 53%
In your ability to direct them to community resources 53%
In your ability to identify vulnerable patients 53%
In your ability to deal with mental health issues 47%
In your ability to assess capacity and navigate consent issues
41%
In your ability to provide health promotion 29%
In your ability to communicate effectively 12%
In your ability to deal with physical health issues 6%
Core Medical Trainees Competencies in adolescent health
August 2012• History taking• The patient as central focus of care• Managing long term conditions and promoting
patient self care• Relationship with patients and communication
within a consultation• Health promotion and public health• Principals of medical ethics and confidentiality
The curriculum
Healthy Development
Legal Framework
Communication & Consultation
Health promotion& Advocacy
Chronic Conditions & Transition
Concordance –Adherence
Youth FriendlyServices
Sexual &Reproductive Health
Substance Use & Misuse
Self Harm & Common Mental Health Problems
Overweight &Underweight
Common MedicalConditions
Core SpecialistLevel A
Level B
Level C
Level D
Paediatric
care
Adolescent care
Transfer
Young adult care Adult
care
The “Pull”
Supporting transfer to adult services
The “Push”
Monitoring “the pull” – DNA Policy
36 transferred to tertiary adult
service
2 no appointment sent
2 lost (early)
34 sent an appointment
10 failed to attend first
appointment
6 lost (4 early)
24 attended first appointment
5 failed to attend second
appointment
4 lost(3 early)
19 attended second
appointment
6 lost(2 early)
Gleeson et al. Clinical Endocrinology 2013
50% lost50% attended first two appointments
Indicative of engagement
Navigating “the pull” -Transitional care coordinator
Holmes-Walker 2007Retrospective cohort study of 191
young people with IDDM
Length of hospital stay
DKA admissions and readmissions
Reduction in HbA1c of 0.13% but greater in
those with HbA1c >11.1%
Cost neutral
Young Adult Clinics – improving the crash landing?
Harden P et al BMJ 2012
Getting the Balance Right
Healthcare systems &
training structures
Self management
of chronic disease
Principles of Adolescent
Medicine
T
Training for paediatric & adult HCP
Info & resources
Longer appointments
Adherence
Understanding health condition
Managing Health
condition
Growing capacity for self-care
PromotingautonomyConfidentiality
Psychosocial screening
Peer influences
Parents
Risk & protective
factors
Transitioncoordinators
Data systems
(Kennedy A & Sawyer SM 2008)
Summary
• Developmentally appropriate care NOT transition
• Continuity NOT models
• Training• All areas of adult services NOT just outpatients