Integrating an EMR-based Transition Planning Tool for CYSHCN at a Children's Hospital: A Quality Improvement Project to Increase Provider Use and Satisfaction

• The process of being introduced to and using the TPT promoted a greater understanding of the complexity and need for transition planning processes overall.
• Prior to being exposed to the TPT providers assumed the patients knew more about their illness than they actually did.
• The tool's structure prompted providers to be more patient-centered, directing their discussions at the patient's actual knowledge base.
• Physicians were not the primary adopters of the TPT.
• TPT uptake was enhanced when a person(s) whose responsibilities include HCT planning with YSHCN and families was identified.
• Any TPT must be adapted to the users' feedback.

An electronic medical record (EMR)-based transition planning tool (TPT) designed to facilitate transition from pediatric to adult-based health care for youth (16–25 years) with special health care needs was introduced at a large children's hospital. Activities to increase provider use were implemented in five plan–do–study–act cycles. Overall, 22 of 25 (88%) consenting providers in four pediatric subspecialty services used the TPT during 303 patient encounters, with nurses and case-managers the top users and physicians the least likely users. Use was highest with intensive technical assistance and following the introduction of an upgraded tool. Provider satisfaction with the TPT and self-reported transition planning activities notably increased across the PDSA cycles.