Table 3 Requirements of Ideal Transition Care for Autoimmune Rheumatic Patients in RSCM
From: Autoimmune rheumatic transitional care model development
Transition Care Requirements | Coding | Background | Current situations | Perception regarding Ideal Model of Transition Care |
|---|---|---|---|---|
Transfer document | -Documents requirement for transition (pediatric to rheumatology clinic) -Suggestions regarding transfer document | -Pediatrician (A1): “there’s no transfer document approved by both pediatrician and rheumatologist, we have filled the transfer document but it’s not delivered to rheumatology clinic.” -Pediatric Administration (MA): “Transition patients will bring a consultation letter and letter of patient’s history.” -Patient (P1): “We bring all the laboratory results from pediatric clinic to rheumatology clinic, and we’ve got interviewed over and over again.” -Psychiatrist (PS): “Patients feel traumatized to be asked about their painful experience allover again, and they also afraid that the doctors don’t understand about their condition. We have to make a transfer method that approved by both pediatrician and rheumatologist.” | -Rheumatology nurse (CR): “There are medical resume and drug records in that resume letter. We will make a report if there are any problems identified” | -Pediatric Administration (MA): “The transfer document should be made by doctors because of their knowledge regarding the medications.” -Rheumatologist (R1): “A good transfer document shoud consist of complete medication history and medication planning, including the reason of stopping or switching any medications in order to assure the medication continuity… it can be adopted from ACR.” -Rheumatologist (R2): “Previous attending physician’s note can guide our next management planning.” -Pediatric nurse (PA): “Paper documents can be lost, its better to be integrated within electronic medical records.” -Rheumatology nurse (PR): “Electronic medical record might need longer time to processed, we can use paper documents temporarily.” |
Standard Operating Procedure | -Transition age -Transition algorhythm -Continuation of patient care -Care guideline -Healthcare worker’s coordination -Hospital management’s role in autoimmune rheumatic transition care process -Efforts made by Pediatric clinic -Efforts made by Rheumatology clinic | -Pediatrician (A2): “There’s a confusion regarding the treatment for patient aged 17.5 years-old but still require our intensive monitoring, but the National health insurance strictly regulate the transfer the patients aged 18 years-old to internal medicine clinic.” -Pediatric Administration (MA): “Sometimes we noticed that there’s still patients undergone certain protocol in pediatric clinic and haven’t get transferred although they have reached 18 years-old until the medication protocol was done.” -Rheumatology Administration (MR): “Patients aged 17 years-old in rheumatology clinic can be examined due to certain social indications, and then will be refered to pediatric clinic…” | -Pediatrician (A1): ““For special cases, we have tried to invite the internal medicine team from which we would transferred the patient to…,we have made Whatsapp group to communicate with patients and caregivers along with pediatric and rheumatologist…for patients having dificulties to understand the information, we will refer them to the psychiatrist. We also have plan to make tutorial video of transfer procedure.” - Pediatric Administration (MA): “when patients reached 18 years-old, we will transfer them to internal medicine clinic with a letter of patient’s history, and we have told them about the location of internal medicine clinic, the online registration process, and the location of pharmacy.” -Rheumatology nurse (PR): “We (the nurse) have been communicating with our patients through Whatsapp.” | -Pediatrician (A1): “…the education about transition care can be started as early as 16 years old…special case meeting should be held for every 3 months.” -Psychiatrist (PS): “…there should be a case manager focused in educating the patients and caregivers…” -Rheumatologist (R1): “The transition patients should be prioritized and meet the attending physician each month for their first 6 months of transition.” -Pediatrician (A1): “We need to make special routine forum every 3–6 months prior to transition, to discuss about their condition.” -Pediatrician (A2):“The transition care can’t be handle by a temporary doctor, there has to be a person in charge of transition process.” |
Coordination forum | -Administration information for patients -Suggestions regarding patient care | -Psychiatrist (PS): “…(20–70% of patients have neurocognitive disorder, thus they are having trouble receiving so many informations, maybe we should explain the whole process starts from registration department…” -Psychiater (PS): “Patients need 3 months or more to adapt in the new situation.” | -Pediatrician (A1): “…we have made Whatsapp group to communicate with patients and caregivers along with pediatric and rheumatologist…” | Rheumatology nurse (PR): “Make a coordination forum of communication between patients, caregivers, and healthworkers involved in healthcare transition.” |
Transition clinic | -Crowds condition -Transition clinic | -Pediatric Administration (MA):“…we should make a special day for rheumatology clinic to accept the transition patients, so that the patients can meet their peer group.” -Rheumatology Administration (MR): “The suggestion regarding special day is difficult to carried, there must be difficulties to separate their age from registration department.” -Pediatrician (A1): “In Internal Medicine clinic there are more patients (around 100 patients) compared with Pediatric clinic (50 patients maximum).” | No special activity | Rheumatologist (R2): “Pediatric clinic inform the transition patients to visit rheumatology clinic on certain day, to a transition care room in rheumatology clinic with a person in charge.” |