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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 care. These transition resources are consistent with the AAP/AAFP/ACP Clinical Report on Transition.

We recognize that family medicine and med-peds providers play three distinct roles in the transition process. These roles include:

  1. providing developmentally appropriate care for youth and young adults who remain within the practice as they transition to an adult approach to health care,
  2. transitioning youth and young adults to different adult providers when they move or go away to college, and
  3. accepting and integrating new young adult patients who have transferred from other providers.

The tools in this section pertain only to this first role—assisting youth and young adults who remain with the practice from childhood to adulthood and require transition support to be ready for an adult approach to care (e.g. managing their own care, understanding privacy and consent.) Corresponding sections of the website describe transitioning youth and young adults to different adult providers (#2 above) and accepting and integrating new young adult patients who have transferred from other providers (#3 above).

Recognizing and responding to the diversity among youth 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.1 In addition, engaging youth, young adults, and parents/caregivers from various cultural backgrounds in the development and evaluation of a transition quality improvement process is important.2

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 young adults.3 The process begins with the creation of a collaborative team that could include physicians, nurse practitioners, physician assistants, nurses, social workers, care coordinators, medical assistants, administrative staff, IT staff, and young adult/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 young adult in order to pilot the pediatric and adult delivery system changes needed for transition. Sample tools that can be customized for use in primary and specialty care are available in this package and on www.GotTransition.org.

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) 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/

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

3) 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.



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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