Health transition tips and resources for healthcare providers

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

Table of Contents

Overview

Research shows the majority of young adults generally do not receive recommended transition supports, 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

Sample transition policies for practices

Readiness assessments for individual, group and network practices

Six Core Elements 2.0
The new version is accompanied by 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

Health Care Transition — Measure It — Got Transition has developed two different measurement approaches to assess the extent to which the Six Core Elements of Health Care Transition 2.0 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

Web-based CME opportunities

  • Physician Education in Developmental Disabilities
    The series is designed to enhance the practice skill of primary care physicians and residents who would like to provide better care to their adult patients with developmental disabilities. Each webinar is accredited by the American Academy of Family Physicians for 1.0 hours of prescribed credit (recognized by the AMA as equivalent to Category 1 credit). A total of up to 12.0 credit hours are available, at no cost, for those who participate in all of the webinars. The webinars are available for CME continuing medical education credit only. If you are not a physician please check with your specific professional or licensing board to see if this series will qualify for your educational requirements.
  • 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

Contact

Phone

Community Support Line (800) 882-1435
Contact the Division (617) 994-9815

Online

Elaine M. Gabovitch, MPA Elaine.Gabovitch@State.MA.US

Address

250 Washington St.
Boston, MA 02108

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