Development and Implementation of a Psychoeducational Model for a Pediatric MS Clinic Transition Program

Background: Multiple Sclerosis (MS) is less commonly diagnosed in children than in adults with an estimated prevalence of 5,000 in the US and 10,000 worldwide, compared to the total estimated number of 1 million cases in the US and 2.3 million worldwide. Within the pediatric age group, the incidence is highest in those between 13 and 16 years of age. No matter their age at the time of diagnosis, children eventually mature and become adults living with MS. In the last decade, the process of transition of care of adolescents with special health care needs has been recognized as a priority. Transitional healthcare is the purposeful movement of young adults with chronic physical and medical conditions from a child-centered to an adult-centered healthcare system. Transition in the MS population is critical as it happens at a time when young patients are at risk for lapses in insurance coverage, not seeing appropriate providers, losing access to necessary medications, increase use of acute care settings like the emergency department and loss of independence and functioning. Poorly planned transition may lead to psychosocial distress, mental health concerns, and increased medical vulnerabilities. A number of barriers may inhibit successful transition, including poor preparation, lack of communication on the part of healthcare providers, resources unavailable to patients, and other barriers. As such, it is critical that healthcare providers understand models for clinic transition programs that they may implement in their practice settings.

Objectives: 1) To present a model for a clinic transition program that engages psychoeducation to aid young adults in a healthy and successful transition; 2) To educate clinicians about critical transition elements across the core stages of transition.

Methods: Individuals between ages 10-21 and their primary caregivers who seek care at the southeastern pediatric MS Center will enroll in a psychoeducational transition program using a transition model that incorporates holistic healthcare in transition. Data from these individuals, their caregivers, and their current healthcare providers will be analyzed to evaluate the effectiveness of the implementation of the program on the pediatric MS practice. Data will be collected regarding the development of a transition care policy, initial and ongoing transition readiness assessments, evaluation of individual care plans and documentation of medical summaries, as well as the identification of variations in the adult care model with written preparation of transfer of care.

Results: Beginning implementation of the program will be June 1, 2021. Preliminary results expected in Fall of 2021.

Conclusions: Presenters will overview transition data alongside with best practices for engaging a psychoeducational transition program in clinical practices.