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Intro
Six Core Elements
1
Transition Policy
2
Tracking & Monitoring
3
Transition Readiness
4
Transition Planning
5
Transfer
of Care
6
Transfer Completion
Measuring Transition

Transition Planning/Integration into Adult Practice

  • Communicate with young adult's pediatric provider(s) and arrange for consultation assistance, if needed.
  • Prior to first visit, ensure receipt of transfer package (final transition readiness assessment, plan of care with transition goals and pending actions, medical summary and emergency care plan, and, if needed, legal documents, condition fact sheet, and additional provider records.)
  • Make pre-visit appointment reminder call welcoming new young adult and identifying any special needs and preferences.
  • Provide linkages to insurance resources, self-care management information, and culturally appropriate community supports.

Description

Planning with the pediatric provider for the transition of young adults is the fourth element in these health care transition recommendations. Adult practices should ensure receipt of the young adult's transfer package from the pediatric practice. A transfer package should include a final transition readiness assessment, plan of care, medical summary and emergency care plan, and, if needed, legal documents, a condition fact sheet and subspecialist records. The adult practice must communicate with the pediatric practice about their residual responsibility for care until the first visit to the adult provider is completed. Until the young adult has gone to the first appointment and established care in the new medical home, the pediatric provider has some residual responsibility for care (e.g. medication refills or acute care visits). In the case of young adults with complicated health or psychosocial needs, direct provider communication is encouraged. Adult providers can also establish a plan for further consultation with the pediatric provider should the need arise. After all records are obtained and the pediatric practice is contacted, the adult practice should make a pre-visit call to welcome the patient, remind them of their upcoming appointment, and identify any special needs or preferences. Community resource information on insurance, self-care management, and culturally appropriate supports can be helpful to young adults.



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Got Transition™ is a program of National Alliance Logo The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB