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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

Introduction

The Six Core Elements of Health Care Transition 2.0 define the basic components of health care transition support and the corresponding sample tools provide tested means for transitioning youth to adult health care providers. These transition resources are consistent with the AAP/AAFP/ACP Clinical Report on Transition.

To implement the Six Core Elements, a quality improvement approach is recommended. Plan-do-study-act (PDSA) cycles provide a useful way to incrementally adopt the Six Core Elements as a standard part of care for youth and their families.1 The process begins with the creation of a collaborative pediatric and adult team that could include physicians, nurse practitioners, physician assistants, nurses, social workers, care coordinators, medical assistants, administrative staff, IT staff, and youth/young adults and families. Leadership support from the practice, plan, or academic department is critical as well. Oftentimes, practices decide to begin with a subset of youth in order to pilot the pediatric and adult delivery system changes needed for transition.

Recognizing and responding to the diversity among youth, young adults and their families is essential to the transition process. This diversity may include but is not limited to differences in culture, race, ethnicity, languages spoken, intellectual abilities, gender, sexual orientation, and age. Since implementation of the Six Core Elements depends so much on patient and provider communication, health plans and practices should use appropriate oral and written communications, including interpretation and translation services and health literacy supports as needed.2 In addition, engaging youth and parents/caregivers from various cultural backgrounds in the development and evaluation of a transition quality improvement process is important.3

An overview of the development of the Six Core Elements of Health Care Transition 2.0 is available. Got Transition welcomes your comments and feedback on the Six Core Elements model, which can be sent to info@GotTransition.org. Thank you for your interest in the successful health care transitions of youth and young adults from pediatric to adult-centered care.



1) Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality and Safety. 2013:0;1.

2) Additional information can be found at: http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/index.html and at: http://www.health.gov/communication/literacy/

3) Additional information can be found at www.thinkculturalhealth.hhs.gov



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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