Health transition tips and resources for healthcare providers

Health care providers are key to successful transitions from the pediatric to the adult medical home.

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Research shows the majority of adolescents generally do not receive recommended supports for the transition from pediatric to adult health care, including:

  • Early and ongoing assessments of self-care skills
  • Engagement and support for developing self-care skills preparation for adult-centered care, including changes in privacy and consent
  • Assistance with identifying adult providers
  • An organized process for transfer to adult providers, and
  • Opportunities to provide feedback

Depending on the needs of the young person, there may be one or more specialty care providers who may need to be involved early on in the process. Ideally, each new adult provider will be knowledgeable about the young person’s health condition or disability and its treatment, and will be someone with whom the young person feels comfortable.

When there is a clear pediatric practice transition policy, medical self-management skills are supported early on by the pediatric provider, specialists, parents and the youth, and a clear, coordinated transition plan is developed by all, including potential adult providers, transition is most successful.

The links below are only some of the sites that can provide you as either a pediatric or adult provider with tools and support to coordinate a successful transition, research, and CME opportunities for understanding and working with young adults with special healthcare needs.


Sample transition policies for practices

Got Transition(TM) readiness assessments for individual, group and network practices

Six Core Elements
The Got TransitionTM Six Core Elements have 3 tool packages:

  • Transitioning Youth to Adult Health Care Providers for use by Pediatric, Family Medicine, and Med-Ped Providers
  • Transitioning to an Adult Approach to Health Care without Changing Providers for use by Family Medicine and Med-Peds Providers
  • Integrating Young Adults into Adult Health Care for use by Internal Medicine, Family Medicine, and Med-Peds Providers

QI tools and surveys

Got TransitionTM has developed two different measurement approaches to assess the extent to which the Six Core Elements of Health Care Transition are being incorporated into clinical processes:

  • Current Assessment of Health Care Transition Activities
    This is a qualitative self-assessment method that allows individual providers, practices, or networks to determine the level of health care transition support currently available to youth and young adults transitioning from pediatric to adult health care. It is intended to provide a current snapshot of how far along a practice is in implementing the Six Core Elements.
  • Health Care Transition Process Measurement Tool
    This is an objective scoring method, with documentation specifications, that allows a practice or network to assess progress in implementing the Six Core Elements and, eventually, dissemination to all youth and young adults. It is intended to be conducted at the start of a transition improvement initiative - as a baseline measure, and then repeated periodically to assess progress.


Web-based CME opportunities

  • Web-based Curricula for Transition Care Improvement
    The curricula are change packages designed to help participants increase their medical home capacity through improvements to transition care. Both courses use a team-based care approach to address specific barriers identified by practicing physicians. There are both pediatric and adult practitioner courses credited by the AMA. The courses are available to any medical provider nationally.
  • Health Services for Children with Special Needs
    An online CME video course for physicians who would like to improve transition services in their practice. The course is designed and recommended for physicians to prepare youth and their caregivers to assume responsibility for managing their chronic conditions and transfer from a pediatric to adult care setting.

Guides, videos, and manuals

  • Supporting Self-Management in Children and Adolescents With Complex Chronic Conditions
    Self-management improves health outcomes in chronic illness not only by improving adherence to the treatment plan but also by building the individual’s capacity to navigate challenges and solve problems.
  • Moving On Positively: A Guide For Youth, Caregivers, and Providers (PDF) | (DOC)
    For use by youth and young adults, parents and caregivers.
  • CROSSINGS: A Manual for Transition of Chronically Ill Youth to Adult Health Care
    This manual is intended as a guide for health professionals to establish a new health care delivery system for transitioning adolescents with chronic illness to adult healthcare. The manual is based on the experience of a cystic fibrosis team in a hospital for children and a department of internal medicine, in collaboration with other appropriate hospital departments.
  • "We Are Able" Video
    This film aims to raise awareness and offer suggestions as to what policy makers and health care professionals can do to help. The messages in the film come directly from young people with disabilities and/or special health care needs. "We Are Able" was created by the Massachusetts Young Adult Advisory Council, at MDPH.
  • Moving from Pediatric to Adult Providers
    This 16 minute video models a series of steps and strategies pediatricians can take to ensure a successful transition to adult care. The steps include strategic discussions between the pediatrician, youth and parent beginning at age 14, ending with follow-up consultation between the adult provider, young adult and pediatrician.
  • Guide to Health Care Transition (PDF)
    Information for Providers to assist youth to transition to adult health care.

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