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Identification, Screening, Assessment, and Referral

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Eligibility and Enrollment in Health Coverage

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Access to Care

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Medical Home

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Community-Based Services and Supports

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Transition to Adulthood

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Health Information Technology

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Quality Assurance and Improvement

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Transition to Adulthood

Youth with special health care needs receive the services necessary to make transitions to adult care.

Pediatric Health Care Setting:

  1. Transition Policy: A policy about the system’s approach to transition is developed and in place at all levels of the system, including privacy and consent information at age 18 and age of transfer. It should be developed with consumer input and shared and discussed with youth and families beginning at ages 12-14 and regularly reviewed as part of ongoing care. 1
  2. Transition Readiness: A standardized, scorable tool to determine youth’s understanding of self-care and use of health care, initially done with youth and caregiver at age 14 and periodically reassessed by the pediatric provider.
  3. Transfer of Care: The system should be sure providers make the following documents available to the youth’s new provider who serves adult patients (adult provider): a) cover letter, b) final transition readiness assessment, c) updated plan of care, d) updated medical summary and emergency care plan, and e) if needed, legal documents, condition fact sheet, and additional provider records. There should also be a process in place to confirm with the adult provider residual responsibility for patient care until the young adult is seen in the adult care setting.
  4. Transfer Completion: The system should ensure that there is communication with the adult provider confirming transfer and offering pediatric consultation assistance as needed. The system should contact the young adult/caregiver confirming transfer of care and eliciting feedback on experience with transition process.

Adult Health Care Setting:

  1. Young Adult Transition and Care Policy: The system should have a policy/statement about the practice’s approach to accepting and partnering with new young adults, developed with consumer input and shared and discussed with young adult at first visit and regularly reviewed as part of ongoing care.
  2. Orientation to/Integration into Adult Practice: The system should identify and list adult providers interested in caring for new young adult patients and be sure there is a young-adult friendly process for welcoming and orienting new young adults into the adult providers’ practices and identifying any special needs and preferences. The system should document if the adult providers received the transfer documents.
  3. Initial Visit: The system should develop an initial visit plan that includes: addressing the young adult’s concerns about transfer, clarifying adult approach to care, conducting self-care assessment, reviewing young adult’s health priorities as part of a current plan of care, and updating and sharing medical summary and emergency care plan.
  4. Ongoing Care: The system should communicate with pediatric practices confirming transfer into the adult practice and need for pediatric consultation assistance and assist young adults with connections to adult specialists and other support services, provide ongoing development of self-care skills and care management, and elicit feedback from the young adult about their experience with their health care.

  • AAP/AAFP/ACP Clinical Report on Transition 2
  • Six Core Elements of Health Care Transition (Version 2.0) 1 (See Appendix A)

  1. Got Transition, Center for Health Care Transition Improvement. Six Core Elements of Health Care Transition 2.0. Available at: http://www.gottransition.org/resourceGet.cfm?id=206. Updated January 2014.
  2. American Academy of Pediatrics. American Academy of Family Physicians, and American College of Physicians. Transitions Clinical Report Authoring Group. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011; 128-182. http://pediatrics.aappublications.org/content/pediatrics/128/1/182.full.pdf