It is important for health care providers and other professionals caring for youth/young adults and their families to establish health care transition processes from pediatric to adult care, for youth with and without special health care needs. Whether you have a pediatric, family, or adult practice/clinic, there are tools available to assist your preparation for the health care transition process.
Got Transition, the national guidance on health care transition policy, suggests using:
- The Six Core Elements of Health Care Transition as a roadmap,
- The Coding and Payment Tip Sheet for Transition from Pediatric to Adult Care, and
- Health Care Transition timeline for a successful process.
How Well is Your Practice Implementing Health Care Transition?
The Six Core Elements can guide physicians through the STEPS of transition.
A policy that describes your practice’s approach to health care transition, to include legal changes that take place in privacy and consent at age 18 and the age when your pediatric practice stops seeing young adults; or, the age when your family/adult practice begins accepting young adults.
- Establish a policy for your provider’s office
- Embrace and share the policy as early as age 12
- Examples: Post a copy in the waiting area, include it with office paperwork, post it on the website or patient portal
- Ensure all staff are familiar with and communicating the policy
- Have regular conversations with all youth and families about the transition policy and what to expect from your provider’s office
Transition Tracking and Monitoring:
A process to identify transition age patients and monitor their progress.
- Use a flow sheet, registry or the electronic health record if possible to track and monitor the progress of transition age patients (14-26) as they move through the six core elements of transition
A method or assessment tool, used yearly, to assess and re-assess healthcare/self-care skills for youth/young adult, and their family, beginning at age 14.
- Choose an assessment tool or method to assess the youth’s ability to perform health care management on their own
- Families should be assessed on their ability to encourage healthcare self-management and assume less of their youth’s responsibility, where possible
- In cases involving total care youth, shared decision-making and/or guardianship should be a focus of readiness and planning. Even then, some skills may be adapted to fit their circumstances
- Both groups should be assessed and monitored regularly
Based on assessment, the plan of care includes transition-related goals and actions.
- Based on readiness assessment findings, develop and regularly update the plan of care with joint goals and actions.
- Provide updates to medical summary and emergency care plan
- Discuss privacy and change of consent that occurs at age 18
- Address supported decision-making for adult-focused health care where necessary
- Identify condition sheets or legal documents, if needed
- Encourage one-on-one time with youth/young adult without parent’s presence
- Acknowledge parent/caregiver’s request to support their youth’s transition efforts
- Provide linkage to community resources, identify adult provider/specialist
- Discuss best timing of transfer to adult provider/model of care
Transfer of Care:
Prepare youth and necessary paperwork to transfer to an identified adult provider.
- For pediatric providers: actively involved in outreach to identify adult providers
- Utilize a transfer package checklist that may include: a letter of transfer, medical summary and emergency form, latest readiness assessment, plan of care, medical records, legal documents, and condition fact sheets (where applicable)
- Confirm information received by the adult provider and attendance at the first appointment
- An adult provider, insurance coverage, or alternate health care facilities have been identified and the youth is prepared to take charge of their health care
- Families should be in a supportive role, where possible, of the young adult’s healthcare needs.
- Adult practices develop transition clinics to help acclimate new patients
- For family physicians, make sure young adult understands the change in the model of care
- Transfer to an adult provider/model of care is recommended before the age of 22
Young adult has attended their first appointment with an identified adult provider or changed from the pediatric to an adult model of care. Feedback about the transition process is gathered and used to improve the transition process.
- Pediatric consultation and assistance offered
- System created to contact young adults and/or caregivers to request feedback about the transition process possibly through a short survey
- Feedback helps to improve health care transition system
Six Core Elements can be altered and used by Other Professionals (school nurses, educational transition specialists, case managers, etc.) who work with youth/young adults and their families within the transition age group to achieve similar goals and outcomes.
Take the full assessment to assess your practice's health care transition progress.
For more information on how to best customize forms for your use, visit Six Core Elements of Healthcare Transition & Samples or contact the Georgia Department of Public Health at [email protected]
Page last updated 12/13/22