302 - Transfer of Care for Adolescents and Young Adults: Early Outcomes from a Centralized Navigation Hub

Saturday, April 29, 2023

3:30 PM – 6:00 PM ET

Poster Number: 302
Publication Number: 302.204

Courtney Porter, Children's Hospital Los Angeles, LOS ANGELES, CA, United States; Jesus Escobar, Children's Hospital Los Angeles, Los Angeles, CA, United States; Rachel Cuevas, Children's Hospital Los Angeles, Downey, CA, United States; Roberta G. Williams, CHLA/USC, Los Anagele, CA, United States; Jennifer Baird, Children's Hospital Los Angeles, Los Angeles, CA, United States

Presenting Author(s)

Courtney Porter, MPH, CPHQ (she/her/hers)

Division Administrator, Center for Healthy Adolescent Transition
Children's Hospital Los Angeles
LOS ANGELES, California, United States

Background: Transition of care from pediatric to adult health systems creates a period of vulnerability for adolescents and young adults (AYA) with chronic conditions. The logistical support needed to identify appropriate adult providers, communicate with payors, and transfer relevant information is time-intensive and requires a level of expertise in systems navigation that most pediatric clinicians do not have. To provide this care coordination support at scale across our organization, we created the Navigation Hub, a centralized team of paraprofessional case managers (‘navigators’) specifically focused on assisting AYA with the transition to adult providers.

Objective:

The purpose of this analysis was to report on outcomes after the initial 2 years (September 2020-November 2022) of implementation of the Navigation Hub.

Design/Methods:

Navigators meet with referred patients to identify patient priorities, explore provider availability within the insurer’s network, and assist with transfer-related coordination and establishment of service with benefit programs. Support continues until transfer-related goals are achieved. All attempted and successful encounters during this initial 2-year period were tracked in a REDCap database with encounters linked by patient, in addition to standard charting within the electronic health record.

Results: Over the 2 years, a total of 943 patients were referred from 13 subspecialty divisions. Of those, 9% (n=83) declined engagement due to lack of interest or need for services. Of the 860 patients who connected and engaged with a navigator, 190 have successfully met their transfer goals to date. Those 190 patients had an average of 16 attempted and 4 successful encounters with the navigator. 61% of patients (n=116) needed assistance with locating an adult primary care provider (PCP); of those, 85% (n=99) had a documented initial visit with the PCP at the time of case closure, and the median time from hub intake to identification of PCP was 48.5 days (IQR: 17.3, 129.8). Demographics for the patients served are found in Table 1.

Conclusion(s):

Transfer of care for AYA is a lengthy process requiring a substantial amount of clinician time for follow-up that is largely uncompensated in current payment models. The use of paraprofessional navigators can successfully support this transfer in a cost-effective manner. This data provides initial evidence to demonstrate the magnitude of the need and the achievement of relevant outcomes, a necessary first step in pursuit of coverage expansion for these services in insurance plans.