Transition Healthcare Providers

Transitioning Youth to Adult Care   |  Healthcare Providers  |   Other Professionals  |  Youth and Young Adults  |  Families and Support System  |  Resources


It is important for health care provides and professionals, caring for and assisting youth/young adults and their families, to establish health care transition processes from pediatric to adult care, for both 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, suggest using the Six Core Elements of Health Care Transition as a roadmap along with coding and reimbursement tip sheet for Transition from Pediatric to Adult Care and the following recommended timeline for a successful process.

For more information on how to best customize forms for your use contact Georgia Department of Public Health at childrens.medical@dph.ga.gov.

How Well is Your Practive Implementing Health Care Transition

Take the short quiz to assess your practice’s health care transition progress. To take the full assessment check out: https://www.gottransition.org/providers/leaving-measure.cfm

  1. There is a written transition policy/statement that describes the practice’s approach to transition and it is shared with staff and patients?  YES or NO
  2. An established criteria and process exists for identifying transitioning target population and entering them into an individual transition flow sheet or registry?           YES or NO
  3. A transition readiness assessment tool has been adopted for use in practice and incorporated into clinical processes?   YES or NO
  4. A plan of care template that incorporates transition readiness assessment findings, goals, and prioritized actions is used?   YES or NO
  5. There is an established process to match and communicate with selected adult provider?   YES or NO
  6. A self-care assessment tool and medical summary and emergency care plan template has been adopted for use in this practice?   YES or NO
  7. There is a mechanism to systematically obtain feedback from young adult about transition process?   YES or NO

Six Core Elements of Healthcare Transition & Samples

The tips within the following Six Core Elements can guide physicians through the STEPS of transition.

 

  • Transition Policy: 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 with office paperwork, post 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
  • Transition Readiness: 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 child of healthcare self-management and assuming 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.     
  • Transition Planning: Based on assessment, the plan of care includes transition related goals and actions.

    • Based on readiness assessment findings, develop and regularly update 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 adult provider and attendance at first appointment
    • An adult provider, insurance coverage or alternate health care facilities have been identified and 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 change in model of care
    • Transfer to an adult provider/model of care is recommended before the age of 22
  • Transition Completion: Young adult has attended first appointment with identified adult provider or changed from pediatric model to adult model of care; and feedback about the transition process is gathered and used to improve transition process.

    • Pediatric consultation and assistance offered   
    • System created to contact young adult and/or caregiver to request feedback about the transition process possibly through 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.

 

 


Page last updated 11/27/2019