Thanks to improved medical care, children and youth with special health care needs (CYSHCN) are living longer, requiring adult health care. However they generally cannot find adequate services in the adult health care system. Compared with the general population, CYSHCN have a greater variety of health problems but do not receive the same levels of health care. Providers in the adult health care system usually have not been trained and do not know how to provide adequate health care for CYSHSN.
The overall goal of this project is to provide adequate health care transition and an adult medical home for CYSHCN who are patients in Texas Children's Pediatrics primary care practices and need to transition to adult health care services in Harris Health System community clinics. Specific Objectives are to: (1) Formalize and standardize sustainable policies and procedures for transition of CYSHCN from Texas Children's Pediatrics primary care practices to adult health care in geographically proximal Harris Health System community clinics. (2) Increase the number of Harris Health System primary care clinics to a total of 11 clinics actively engaged in building adult health care capacity for CYSHCN. (3) Engage the medical and administrative staff of targeted Harris Health System primary care clinics in the use of transition health care quality improvement methods for CYSHCN transitioning from Texas Children's Pediatrics practices. (4) Increase the number of transitioning Texas Children's Pediatrics CYSHCN to approximately 20 new patients per targeted Harris Health System clinic per year, up to a total of 700 over the 5 years of grant funding. (5) Maintain "enrollment" of the transitioned CYSHCN, including a minimum of one annual primary care well-patient visits and ongoing insurance coverage. (6) Develop a handbook/manual that can be used to replicate this project in other clinic settings, networks, and cities.
The Harris Health System is the county hospital district serving the poor and uninsured in Harris County, TX. There has been no systematic support of transitional health care for CYSHCN in the systems primary care clinics. Dr. Cynthia Peacock, Project Director for this application, has conducted a successful pilot project transitioning CYSHCN patients from several Texas Children's Pediatrics primary care practices to a Harris Health System primary care clinic. Work Plan. Over five years, the Project Team will replicate the successful pilot project methods with two new Harris Health System community clinics per year. This will provide successful transitional health care to a total of 700 new CYSHCN patients, with a sustainable and replicable infrastructure in 11 of the 21 Harris Health System primary care clinics.