Implementation of a comprehensive healthcare transition program incorporating social determinants of health screening for adolescents with rheumatic disease

Transitioning from pediatric to adult healthcare is challenging for young adults and adolescents with chronic disease, especially when socioeconomic barriers are present. This study designed and implemented a comprehensive healthcare transition process to proactively address social barriers to care and prepare pediatric patients with rheumatic disease for successful transition to adult rheumatology. Using quality improvement (QI) methodology guided by the Six Core Elements of Health Care Transition, an interdisciplinary team implemented a structured transition process within a pediatric rheumatology clinic at a tertiary academic center. Established patients aged 14–21 years with rheumatic disease completed a transition readiness assessment questionnaire (TRAQ) and social drivers of health (SDOH) screener every 6 months. The transition educator met with patients to review the TRAQ and teach healthcare management skills. Patients and families with positive SDOH screeners were offered social work consultation. Process measures included the monthly proportion of eligible patients completing screening and receiving transition education, as well as interface with social work among positive SDOH screens requesting assistance. The primary outcome measure was attendance at the first adult rheumatology visit. Patient-level factors associated with successful transfer were examined in secondary exploratory analysis. 190 patients completed the TRAQ, and 171 completed the SDOH screener. On average, 36.3% of eligible patients received transition education monthly, with statistical process control charts demonstrating a stable process within control limits. 13.5% of completed SDOH screeners were positive. Food insecurity, financial burden, and transportation issues were the primary barriers. 88.9% of patients with a positive SDOH screen requesting assistance met with social work. Of the 40 patients eligible for transition outcome analysis, 80.0% attended their first adult rheumatology visit. Referral to adult rheumatology was most strongly associated with first adult visit attendance. Using QI methodology, this study integrated standardized SDOH and transition readiness screening into routine pediatric rheumatology care. This sustainable approach helped identify socioeconomic barriers and connect patients to proactive social support. Referral to adult rheumatology was the factor most strongly associated with successful transfer, highlighting the value of embedding coordinated referral and social support within transition care.