Wednesday, February 5, 2025
2/5/2025
Savithri Nageswaran, M.B.B.S., M.P.H. Voice: (336) 716-6508 Fax: (336) 713-9387 Email: snageswa@wakehealth.edu Website: https://www.wakehealth.edu/Specialty/p/Pediatric-Palliative-and-Complex-Care Problem: Children with medical complexity (CMC) have special healthcare needs, and they require long-term medical, educational, social, and family-support services through various agencies. Coordination of care between providers serving these children is often lacking, resulting in gaps and inefficiencies in care as well as duplication and fragmentation of services. Increasing the proportion of CMC who receive care in a family-centered, comprehensive, and coordinated system is one of the national Healthy People 2030 objectives (Objective MICH-20). Transitioning CMC from pediatric to adult care is important, but fraught with many challenges because of the many providers and services involved in the care of these children. Goals and Objectives: The goals of this project are to (1) create and disseminate a "transition toolkit" that provides comprehensive resources for medical homes and other providers to transition CMC from pediatric to adult care, and (2) provide transition services to 60 CMC using the transition toolkit. Methodology We build on our prior clinical and research experience in delivering care for CMC, and leverage our extensive community relationships built over the past 15 years. Through a systematic process, we will assemble stakeholders in the hospital and community to identify all aspects of transition needs (i.e. medical, social, support etc.), and develop a transition toolkit that includes needs assessment tool, checklist, roadmap, and process/workflow for effectively transitioning children. Using the transition toolkit, an interdisciplinary team will develop individualized transition plan for 60 CMC at Brenner Children’s Hospital, a tertiary care children’s hospital. The team will share the transition plan with m edical homes and coordinate care to implement the plan. Over the project period, we will refine the transition toolkit and disseminate widely. Coordination: This project builds on existing community relationships at the local and state levels. We will work with the State Title V Agency and the North Carolina Pediatric Society to disseminate results to other communities in North Carolina. Our work will be informed by our 20-member advisory board. We will expand our existing community advisory group to include young adults with medical complexity, caregivers, and stakeholders relevant to transition. They will meet regularly and guide the project’s planning, implementation, replication, dissemination, sustainability, and diversity, equity, and inclusion activities. Evaluation: For process evaluation we will use qualitative tools to assess the extent of development and dissemination of the transition toolkit, and the success of implementation in clinical practice. For outcome evaluation, we will use caregiver surveys to assess families’ satisfaction with care at the end of the project compared to baseline. We will evaluate improvement in primary care providers’ perceived skills in transition using surveys at Years 1 and 5.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).