OBJECTIVES

Physical and mental health outcomes of autistic individuals deteriorate during transition to adulthood. The study aims to identify opportunities to improve physician knowledge in health-care transitions (HCT) for autistic individuals by understanding perceived versus experienced facilitators and barriers in overall HCT curriculum implementation in graduate medical education.

METHODS

Medicine-Pediatrics program directors participated in a Health Care Transition Residency Curriculum Collaborative Improvement Network and used an iterative process to develop and improve HCT curricula. Pre- and postcollaborative semistructured interviews were administered to program directors. The study occurred over 9 months (July 2018–February 2019). Recurring interview themes were analyzed utilizing Dedoose qualitative coding software and presented utilizing percentages and proportions.

RESULTS

Most program directors developed curricula in response to a gap in their current transition curricula. All program directors partially or completely met their goals during the collaborative. The most common types of curricular delivery were didactic (65%) and clinical experience-based (53%). Some tested unique delivery platforms, like the electronic medical record system (29%) and online modules (24%). Program directors often involved residents in the curricular development process and overwhelmingly (65%) felt this was a major facilitator. Competing priorities of faculty (71%) and of residents (53%) were the most common barriers.

CONCLUSIONS

Gaps in HCT curricula delivery were primarily attributed to suboptimal health care systems where training occurs, though existing clinical experiences and diverse learning modalities were successfully leveraged. Using a quality improvement framework and actively engaging resident trainees in curriculum development were successful strategies programs used in the development of HCT curricula.

WHAT’S KNOWN ABOUT THIS SUBJECT

Physical and mental health outcomes of autistic individuals deteriorate during the transition to adulthood. Concepts and skills related to pediatric-to-adult health care transitions are not systematically taught in residency training programs, contributing to poor provider knowledge in caring for this population.

WHAT THIS STUDY ADDS

The perspectives of residency training program directors regarding the need for a pediatric-to-adult health care transition curriculum in residency training programs, facilitators and barriers for the same and opportunities that exist within current systems.

Growing evidence highlights the unmet physical and mental health needs of autistic individuals as they transition into adolescence and early adulthood.1,2  Nationally, health systems have not successfully scaled health care transition services, particularly for autistic individuals.3  Despite the growing evidence of its importance, a recent study showed less than 20% of youth receive transition planning support.4  Among youth with special health care needs (YSHCN), autistic youth are half as likely to receive transition services compared with non-autistic youth.5 

Provider knowledge, particularly among adult providers, has been identified as an important barrier in improving health care transitions (HCT) and access among autistic adults.6,7  Research finds that graduate medical trainees feel unprepared to address transition issues with their patients with chronic diseases.8  While health care systems might not be set up to facilitate optimal transitions of care, increased exposure to and training in caring for patients in the transitional age group predicts higher self-reported confidence among trainees.8  Although educational resources have been developed for resident trainees by multiple professional medical organizations, and educational goals and objectives for the topic of HCT have been published,9,10  there continues to be a discrepancy between recommendations from guidelines and resident practice. Taken together, previous research underscores a gap in physician training in HCT for autistic individuals and YSHCN, likely stemming from a larger gap that exists for HCT training in general.6,11 

Physicians dually trained in medicine and pediatrics care for patients across the age spectrum and are in a unique position of enhancing the transition experience for their patients. In the current study, we aimed to understand the experiences of medicine-pediatrics program directors participating in a learning collaborative focused on developing HCT curricula for their resident trainees. In particular, we wanted to determine perceived versus experienced facilitators and barriers in curriculum implementation during the collaborative. Findings from this study could help identify opportunities in improving physician training during graduate medical education on the topic of HCT in autistic individuals.

The study was designed as a prospective cohort study to understand program director experiences before and after participation in a quality improvement learning collaborative described below. The Health Care Transition Residency Curriculum Collaborative Improvement Network (HCT-CoIN) was a national quality improvement learning collaborative over 9 months (June 2018–February 2019), adapted from the Institute for Healthcare Improvement’s Breakthrough Series model.12  The purpose of the HCT-CoIN was to create a toolbox of resources for medicine-pediatrics residency program directors to implement or enhance HCT curricula at their own institutions. Participation in the network was open to all program directors who are members of the Medicine Pediatrics Program Directors Association and participants were provided an incentive of $1000.

Program directors from 19 medicine-pediatrics residency programs across the country (Table 1) participated in the collaborative and were included in the study. Most worked on developing or enhancing a transition-based curriculum, while some worked on developing or enhancing tools to be used for evaluating residents in HCT. Program directors met monthly to present their improvement projects and discuss lessons learned and next steps. One program director withdrew after 4 months of participation; the remaining 18 completed the collaborative.

TABLE 1

Residency Program Characteristics at Baseline

Program CharacteristicsN = 19
Method of curricular delivery, n (%)a  
 Didactics 12 (63) 
 Clinic-based (required) 7 (37) 
 Clinic-based (elective) 2 (11) 
 Online modules 2 (11) 
 Subspecialty rotation 11 (58) 
Clinical setting, n (%)a  
 Academic 13 (68) 
 Community-based 7 (37) 
 Private clinic 3 (16) 
Population demographic, n (%)a  
 Urban 16 (84) 
 Suburban 10 (53) 
 Rural 3 (16) 
Additional program characteristics, median (range)  
 Number of residents or cohort 16 (8–24) 
 Number of core faculty 19 (1–16) 
Program CharacteristicsN = 19
Method of curricular delivery, n (%)a  
 Didactics 12 (63) 
 Clinic-based (required) 7 (37) 
 Clinic-based (elective) 2 (11) 
 Online modules 2 (11) 
 Subspecialty rotation 11 (58) 
Clinical setting, n (%)a  
 Academic 13 (68) 
 Community-based 7 (37) 
 Private clinic 3 (16) 
Population demographic, n (%)a  
 Urban 16 (84) 
 Suburban 10 (53) 
 Rural 3 (16) 
Additional program characteristics, median (range)  
 Number of residents or cohort 16 (8–24) 
 Number of core faculty 19 (1–16) 
a

Nonmutually exclusive categories.

We conducted telephone interviews with all program directors at baseline and after completion of the collaborative. Questions at baseline aimed at understanding the intent behind implementing a transition curriculum, individual program goals, and facilitators and barriers in creating a transition curriculum. Questions at follow-up aimed at understanding how successful program directors were in implementing HCT curricula, whether and how they achieved their goals, and experienced facilitators and barriers.

The qualitative coding scheme (Tables 2 and 3) was developed to capture recurring responses within a set of 4 themes: 1) intent behind curricular development, 2) program goals during the collaborative, 3) facilitators, and 4) barriers. All interviews were coded utilizing Dedoose coding software. To obtain interrater reliability a second coder coded 10% of the transcripts at each data collection period and achieved at least 80% interrater agreement on each code.

The host institution and all programs received exemption from their individual institutional review boards before participation in the collaborative.

TABLE 2

Program Director Interview Responses at Baseline (N = 18)

Coden (%)Example Quotations
Why are you implementing a health care transition (HCT) curriculum in your program?   
 Recognition of health system inadequacies in transition planning 9 (50) “…lack of resources not just from the standpoint of lack of clinic, but there’s not a lot of physicians who have been trained in these areas.” 
 Need for improving care for patients 7 (39) “I think this is what we should be doing–we need this in our curriculum.” 
 Need for improving clinic protocols around transition 6 (33) “Hope to identify ways to better serve those who are transitioning to us from peds” 
 Absence of dedicated transition clinic to deliver or support transition curriculum 6 (33) “In general, we do not have transitional curriculum nor have a great transitional workflow to any capacity…” 
 Absence of transition curriculum for residents 5 (28) “...no standardized curriculum no manpower to develop it…” 
What are your goals in implementing this program (short and long term)?   
 Creating or refining a clinical experience-based curriculum 12 (67) “To have an educational program in place in the next year: didactics and meaningful clinical experiences.” 
 Creating or refining a didactic-based curriculum 10 (56) “We have med peds meetings and lectures…” 
 Matching appropriate transition model to the health care system 7 (39) “Looking towards having a structured inpatient and outpatient transition process on the peds side…” 
 Creating or refining online modules on health care transition 6 (33) “The online educational platform will be the greatest benefit for sustainability.” 
 Developing standardized clinical tools or protocols 3 (17) “…drafted a policy for the institution…” 
 Developing clinical tools using the electronic health record 2 (11) “Biggest barrier is access to EPIC IT group for creating some of the products, particularly the patient registry…” 
 Hiring staff experienced in health care transitions 2 (11) “…hire a transitionalist: work at clinic as well as inpatient, and cares for all transitional-aged patients (hopefully for all, not only patients with high needs).” 
What facilitators do you have in your program to make this a successful endeavor?   
 Leadership or faculty support 9 (50) “He came to MedPeds because of his interest in transition care…he wants to be a champion of care for medically complex patients.” 
 Appropriate capacity in terms of faculty and staff 6 (33) “…I don’t have such a big clinical burden that I’ve had in the past, so I have more administrative time.” 
What do you foresee as being major barriers for implementing this curriculum?   
 Competing priorities of faculty and staff 12 (67) “…time commitment both from the faculty perspective as well as the trainees’ perspectives.” 
 Inadequate number of trained faculty in health care transitions 5 (28) “No clinic nor dedicated faculty yet…” 
How do you think your trainees will respond to this new curriculum?   
 High interest in developing a transition curriculum for program 13 (72) “They are excited about transitions, they mentioned it during their interviews.” 
How have you planned for sustainability?   
 Incorporating a longitudinal curriculum into existing rotations or health system’s structure 11 (61) “…plan on making it a longitudinal curriculum where trainees can build upon their prior knowledge over time,…we are trying to incorporate it in the pediatric advocacy rotation which is more robust…” 
How have you incorporated patients and/or their families into your program planning?   
 Developing an advisory board or committee 4 (22) “We have adolescent leadership advisory board.” 
Coden (%)Example Quotations
Why are you implementing a health care transition (HCT) curriculum in your program?   
 Recognition of health system inadequacies in transition planning 9 (50) “…lack of resources not just from the standpoint of lack of clinic, but there’s not a lot of physicians who have been trained in these areas.” 
 Need for improving care for patients 7 (39) “I think this is what we should be doing–we need this in our curriculum.” 
 Need for improving clinic protocols around transition 6 (33) “Hope to identify ways to better serve those who are transitioning to us from peds” 
 Absence of dedicated transition clinic to deliver or support transition curriculum 6 (33) “In general, we do not have transitional curriculum nor have a great transitional workflow to any capacity…” 
 Absence of transition curriculum for residents 5 (28) “...no standardized curriculum no manpower to develop it…” 
What are your goals in implementing this program (short and long term)?   
 Creating or refining a clinical experience-based curriculum 12 (67) “To have an educational program in place in the next year: didactics and meaningful clinical experiences.” 
 Creating or refining a didactic-based curriculum 10 (56) “We have med peds meetings and lectures…” 
 Matching appropriate transition model to the health care system 7 (39) “Looking towards having a structured inpatient and outpatient transition process on the peds side…” 
 Creating or refining online modules on health care transition 6 (33) “The online educational platform will be the greatest benefit for sustainability.” 
 Developing standardized clinical tools or protocols 3 (17) “…drafted a policy for the institution…” 
 Developing clinical tools using the electronic health record 2 (11) “Biggest barrier is access to EPIC IT group for creating some of the products, particularly the patient registry…” 
 Hiring staff experienced in health care transitions 2 (11) “…hire a transitionalist: work at clinic as well as inpatient, and cares for all transitional-aged patients (hopefully for all, not only patients with high needs).” 
What facilitators do you have in your program to make this a successful endeavor?   
 Leadership or faculty support 9 (50) “He came to MedPeds because of his interest in transition care…he wants to be a champion of care for medically complex patients.” 
 Appropriate capacity in terms of faculty and staff 6 (33) “…I don’t have such a big clinical burden that I’ve had in the past, so I have more administrative time.” 
What do you foresee as being major barriers for implementing this curriculum?   
 Competing priorities of faculty and staff 12 (67) “…time commitment both from the faculty perspective as well as the trainees’ perspectives.” 
 Inadequate number of trained faculty in health care transitions 5 (28) “No clinic nor dedicated faculty yet…” 
How do you think your trainees will respond to this new curriculum?   
 High interest in developing a transition curriculum for program 13 (72) “They are excited about transitions, they mentioned it during their interviews.” 
How have you planned for sustainability?   
 Incorporating a longitudinal curriculum into existing rotations or health system’s structure 11 (61) “…plan on making it a longitudinal curriculum where trainees can build upon their prior knowledge over time,…we are trying to incorporate it in the pediatric advocacy rotation which is more robust…” 
How have you incorporated patients and/or their families into your program planning?   
 Developing an advisory board or committee 4 (22) “We have adolescent leadership advisory board.” 

EPIC, electronic health record system; IT, information technology support; MedPeds, Medicine-Pediatrics faculty group; peds, pediatrics.

TABLE 3

Program Director Interview Responses After Completion of Learning Collaborative (N = 17)

Coden (%)Example Quotations
Do you think your goals were met?   
 Yes, met short-term goals* 6 (35)  
 No, but made progress in short-term goals* 11 (65)  
What were the major changes you made?   
 Creating or refining a didactic-based curriculum 11 (65) “Primarily didactic – some roleplaying, expert on transitional care faculty come in to speak…” 
 Creating or refining a clinical experience-based curriculum 9 (53) “Residents to be more familiar with the transition process and local resources…” 
 Developing standardized clinical tools and protocols 6 (35) “…utilizing checklist tool will be helpful…” 
 Developing clinical tools using the electronic health record 5 (29) “…biggest change was making dot phrases to put in EPIC…” 
 Creating or refining online modules on health care transition 4 (24) “…added entire section on online learning environment related to transition…” 
 Work on noncurricular transition work 4 (24) “…(use) excited transition staff to create videos and participate in educational piece…” 
 Collaboration with subspecialty to build curriculum 4 (24) “…expanding reaching out to subspecialties to see what can offer for caring for patients…” 
How did you use the HCT curriculum (from the collaborative) in your program?   
 Learning from and sharing with peers enabled better curricular planning 5 (29) “Participating in collaboration helpful – can be easy to get discouraged but having deadline and following in QI format helpful to stay accountable” 
What was your approach in implementing changes?   
 Conducted a needs assessment among residents and faculty 9 (53) “…getting sense of what needs are – speaking to stakeholders, needs assessment…” 
 Using a quality improvement framework 3 (18) “…doing multiple PDSA cycles…through monthly calls helped and was successful…” 
What facilitators helped you implement the curriculum?   
 Involving residents in the process 11 (65) “…residents enjoy and are on same page in terms of curriculum…” 
 Faculty support 11 (65) “Need champions in several areas other than yourself – need reliable people and more collaborators” 
What were your barriers to implementation?   
 Competing priorities of faculty and staff 12 (71) “…everyone is always pulled in different directions in terms of scheduling…” 
 Competing priorities of resident trainees 9 (53) “…finding time to get things done, everyone is always pulled in different directions in terms of scheduling…” 
 Inadequate number of trained faculty in health care transitions 3 (18) “I need more faculty development with faculty who are interested in teaching transition.” 
 Lack of leadership support 2 (12) “…having people in higher-up positions be supported…” 
 Limitations with health care insurance 2 (12) “…huge barrier is insurance…” 
Which changes that you made will be sustainable?   
 All changes made during collaborative 9 (53) “…sustainable because of strong belief, faculty awareness…” 
What surprising or unanticipated outcomes (positive or negative) occurred during the course of your project?   
 Inability to easily identify patient population ready for transition 5 (29) “…the patient population is hard to locate…” 
Coden (%)Example Quotations
Do you think your goals were met?   
 Yes, met short-term goals* 6 (35)  
 No, but made progress in short-term goals* 11 (65)  
What were the major changes you made?   
 Creating or refining a didactic-based curriculum 11 (65) “Primarily didactic – some roleplaying, expert on transitional care faculty come in to speak…” 
 Creating or refining a clinical experience-based curriculum 9 (53) “Residents to be more familiar with the transition process and local resources…” 
 Developing standardized clinical tools and protocols 6 (35) “…utilizing checklist tool will be helpful…” 
 Developing clinical tools using the electronic health record 5 (29) “…biggest change was making dot phrases to put in EPIC…” 
 Creating or refining online modules on health care transition 4 (24) “…added entire section on online learning environment related to transition…” 
 Work on noncurricular transition work 4 (24) “…(use) excited transition staff to create videos and participate in educational piece…” 
 Collaboration with subspecialty to build curriculum 4 (24) “…expanding reaching out to subspecialties to see what can offer for caring for patients…” 
How did you use the HCT curriculum (from the collaborative) in your program?   
 Learning from and sharing with peers enabled better curricular planning 5 (29) “Participating in collaboration helpful – can be easy to get discouraged but having deadline and following in QI format helpful to stay accountable” 
What was your approach in implementing changes?   
 Conducted a needs assessment among residents and faculty 9 (53) “…getting sense of what needs are – speaking to stakeholders, needs assessment…” 
 Using a quality improvement framework 3 (18) “…doing multiple PDSA cycles…through monthly calls helped and was successful…” 
What facilitators helped you implement the curriculum?   
 Involving residents in the process 11 (65) “…residents enjoy and are on same page in terms of curriculum…” 
 Faculty support 11 (65) “Need champions in several areas other than yourself – need reliable people and more collaborators” 
What were your barriers to implementation?   
 Competing priorities of faculty and staff 12 (71) “…everyone is always pulled in different directions in terms of scheduling…” 
 Competing priorities of resident trainees 9 (53) “…finding time to get things done, everyone is always pulled in different directions in terms of scheduling…” 
 Inadequate number of trained faculty in health care transitions 3 (18) “I need more faculty development with faculty who are interested in teaching transition.” 
 Lack of leadership support 2 (12) “…having people in higher-up positions be supported…” 
 Limitations with health care insurance 2 (12) “…huge barrier is insurance…” 
Which changes that you made will be sustainable?   
 All changes made during collaborative 9 (53) “…sustainable because of strong belief, faculty awareness…” 
What surprising or unanticipated outcomes (positive or negative) occurred during the course of your project?   
 Inability to easily identify patient population ready for transition 5 (29) “…the patient population is hard to locate…” 

EPIC, electronic health record system; PDSA, plan-do-study-act; QI, quality improvement.

a

Mutually exclusive answers.

There were 18 of the 19 program directors who completed the baseline interview and 17 of the 18 programs who completed the follow-up interview. The participating program characteristics are outlined in Table 1.

Program directors wanted to implement HCT curricula because they understood the importance of transition planning in the overall care of patients (39%) but recognized their health systems’ inadequacies in addressing transitions (50%) (Table 2). A program director stated “…there’s not a lot of physicians who have been trained in these areas.” About a third of the programs (28%) did not have any transition curriculum at the time of the baseline interview.

Most program directors at baseline (67%) planned on developing a clinical experience-based curriculum, and 53% of program directors at follow-up were successful in doing so. More than half (56%) of program directors planned to adopt a didactic-based curriculum at baseline; 65% reported successful adoption at follow-up (Tables 2 and 3). Seventeen percent of programs planned on developing clinic-based tools and protocols for transition; more than twice the number of programs were successful in doing so by the end of the collaborative (35%), citing “…utilizing a checklist tool will be helpful…”. Similarly, 11% planned on using the electronic health record as a curricular tool and 29% were able to develop these, noting “…biggest change was making dot phrases to put in EPIC (electronic health record system) …” Although not initially reported as goals at baseline, several program directors cited the ability of faculty to work on transition projects outside of the residency curriculum (24%), and collaboration with subspecialties to deliver the curriculum (24%) at follow-up.

All program directors reported that they met their goals at least partially (6 programs met all short-term goals while 11 programs partly met their short-term goals). The majority (53%) felt they would be able to sustain changes that were adopted during the collaborative.

At baseline, program directors felt that leadership and faculty support and faculty and staff capacity would be the biggest facilitators in curriculum development (50% and 33% respectively) (Tables 2 and 3). At follow-up, program directors stated actively involving residents in the curricular development process served as an important facilitator (65%), in addition to faculty support (53%), reporting “…residents enjoy and are on same page in terms of curriculum…”.

Barriers identified at baseline by program directors also held true at follow-up: competing priorities of faculty and staff (67% at baseline, 71% at follow-up) and insufficient number of trained faculty in transitional care (28% at baseline, 18% at follow-up) (Tables 2 and 3). Another important barrier identified at follow-up was competing learning priorities for residents (53%): “…finding time to get things done, everyone is always pulled in different directions in terms of scheduling…” An unanticipated finding on follow-up was the fact that patients ready for transition care were not readily identifiable among the scheduled clinic patients (29%). System-based barriers, such as lack of leadership support and insurance difficulties, were less common among programs at follow-up (12% each).

The transition into adulthood is a vulnerable period, as well as an opportunity to promote lifelong physical and mental health for emerging adults, that requires strategic coordination of services.13  Disparities during this transition are higher for YSHCN, but particularly for autistic individuals.4,5  A knowledge gap exists among providers, particularly adult providers caring for autistic individuals,6,7  and enhancing graduate medical education learning experiences in HCT in a diverse patient population could help fill this gap. Developing a curriculum can improve the confidence among resident trainees in addressing transitions of care among peers and families alike.8,14  Ours is the first study to investigate program directors’ perspectives while adopting transition curricula in medicine-pediatrics residency training programs during a national learning collaborative.

Similar to prior studies,9  program directors in the study highlighted health system inadequacies in addressing transitions into adulthood. Despite this, all programs were successful in meeting and progressing in their goals of developing a transition curriculum during the collaborative. The finding is a testimony to the strength of learning collaboratives and the impact of using a quality improvement framework in curricular development.12 

Resident trainees appreciate having diverse modalities of HCT curricula.15  Our study found didactic- and clinical experience-based learning were most popular while delivering HCT curricula. Other modalities which were used included online modules, the electronic health record system, and clinic protocols. Our study was therefore able to attest to the feasibility and acceptability of using diverse educational platforms and strategies for graduate medical trainees, as recommended by the Transitions Clinical Report Authoring Group.9 

Program directors leveraged resident participation in HCT curricular development, alongside faculty support, and found these to be major facilitators. These might be particularly important when health systems lack dedicated staff, faculty, and infrastructure to deliver optimal transition care. However, while resident trainees were major facilitators, they posed a barrier because of their busy schedule and competing learning priorities. Therefore, transition curricula should be incorporated in existing clinical experiences.9 

While our study focused on understanding perspectives around HCT curricula implementation and improvement in general, there are some key takeaways that could benefit physician educators focused on improving health outcomes for autistic individuals. Because the health care transition experience for autistic individuals varies across the country, educators could use an iterative process of a quality improvement framework and include resident trainee perspectives during curriculum development in addressing contemporary health problems relevant to their patient populations. In addition, if lack of patient diversity during residency training impedes learning, results from this study highlight that online modules and simulation cases of autistic individuals can be successfully incorporated into HCT curricula.

There were a few limitations to the study. The baseline surveys were conducted by multiple study team members, which could have introduced some bias in how questions were asked. None of the interviews were recorded and, therefore, notes taken during the interview could not be verified at a later time. Our sample consisted of mainly academic centers and, therefore, does not necessarily reflect the state of transition curricula across different program settings.

In reducing the physical and mental health fallout that occurs during the transition to adulthood, it is important to train health care providers to adequately care for transitional-age youth, particularly for autistic youth with special health care needs. A quality improvement framework provides program directors structure in developing HCT curricula even within suboptimal health care settings. Existing clinical experiences and diverse learning modalities should be leveraged to deliver HCT curricula. Resident trainees should be actively engaged in the curriculum development process.

We thank the Medicine Pediatrics Program Director Association and all the programs and program directors who participated in the Health Care Transition Residency Curriculum Collaborative Improvement Network Transition Research.

Dr Fernandes designed the data collection instruments, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content; Dr Hotez conducted the analyses, drafted the initial manuscript, and critically reviewed the manuscript for important intellectual content; Mr Timmerman conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Haley and Ms Reyes collected data and reviewed and revised the manuscript; Dr Ferguson conducted the initial analyses and reviewed and revised the manuscript; Dr Kuo conceptualized and designed the study, designed the data collection instruments, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Health Care Transitions Research Network for Youth and Young Adults with Autism Spectrum Disorders, grant UA3MC27364.The information, content and/or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US Government.

HCT

health care transition/s

HCT-CoIN

Health Care Transition Residency Curriculum Collaborative Improvement Network

YSHCN

youth with special health care needs

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Competing Interests

CONFLICT OF INTERST DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.