Transition of Care: Lessons from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Dialysis Collaborative

Abstract Acknowledging the importance of preparing the pediatric dialysis patient for successful transfer to an adult provider, centers from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Dialysis Collaborative developed transition tools and performed iterative implementation of a transition of care program to gain real life insight into the drivers and barriers towards implementation of a transition program for patients receiving dialysis. 9 educational modules, along with introductory letter and assessment tool were created. A 4-month pilot implementation study among 6 centers of varying patient population (age ≥ 11 years) was performed. TOC tools were further refined and broader implementation within the collaborative was performed. Interim assessment of TOC tool utilization and implementation success was performed among 11 centers, forming the foundation towards a broader discussion regarding process, barriers and success towards TOC implementation among 26 centers. Transition champion was a key driver of successful implementation. Lack of institutional support and collaboration with adult dialysis centers were important barriers towards sustainability. COVID pandemic and increased staff turnover affected longer term implementation of TOC program. Successful transition and transfer of AYA with ESKD on dialysis remains a challenge. This study represents the experience of the largest cohort of pediatric dialysis centers, with diversity in population size and geography, towards development and implementation of a TOC program. The collaborative adds to the resources available to assist a center towards transition and transfer, with particular focus on transitioning patients on dialysis.