Health transition tips and resources for healthcare providers

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

Overview

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.

Reports

• Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home
  A joint clinical report from the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians. The report aims to advance the practice-based implementation of planning, decision-making, and documentation processes for youth with chronic or medically complex heath care needs.
• Current Status of Transition Preparation among Youth with Special Needs in the United States
  This study examines the current US performance on transition from pediatric to adult health care and discusses strategies for improvement. 

Sample transition policies for practices

• George Washington Internal Medicine Clinic Privacy Statement (PDF)
  A sample policy statement for young adults 18 and over with chronic and complex medical needs.
• Sample Transition Policy from Got Transition^TM
  A sample policy/statement describing the practice’s approach to working with youth to develop independence and self-care needs, including the legal changes that take place in privacy and consent at age 18; Sample is also available in Spanish.

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

Six Core Elements
The Got Transition^TM 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 Transition^TM 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.

Algorithms

• Health Care Transition-planning Algorithm for all Youth and Young Adults within a Medical Home Interaction (fig. 1)
  For pediatric practices, transfer to adult provider as recommended by the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians joint clinical report: Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home, 2011.
• Health Care Transition-planning Algorithm for all Youth and Young Adults within a Medical Home Interaction (fig. 2)
  Figure 2 contains descriptive text for each of the algorithm components in figure 1.
• Health Care Transition Preparation for Youth and Young Adults with Special Health Care Needs in Florida
  FloridaHATS (Health & Transition Services) has developed a transition algorithm that has medical transition at the core, but also encompasses all other transition points for young adults, including healthcare coverage, education and vocational rehabilitation.

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.