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Six Core Elements
Transition Policy
Tracking & Monitoring
Transition Readiness
Transition Planning
of Care
Transfer Completion
Measuring Transition

Transition Planning/Integration into Adult Approach to Care

  • Develop and regularly update a plan of care, including readiness assessment findings, goals and prioritized actions, medical summary and emergency care plan, and, if needed, legal documents.
  • Prepare youth and parent/caregiver for adult approach to care at age 18, including legal changes in decision-making and privacy and consent, self-advocacy, and access to information.
  • Determine of need for decision-making supports for youth with intellectual challenges and make referrals to legal resources.
  • Plan with youth and parent/caregiver for optimal timing of transfer from pediatric to adult specialty care.
  • Obtain consent from youth/guardian for release of medical information.
  • Provide linkages to insurance resources, self-care management information, and culturally appropriate community supports.


Planning for transition as a collaborative and continuous process with youth and families is the fourth element in these health care transition recommendations. It encompasses several activities. To begin with, it is important to develop and regularly update a plan of care that identifies the youth's priorities and addresses how learning about health and health care can support their priorities. In addition, to further youth's independence, developing and sharing a medical summary and emergency care plan and establishing linkages to community-based supports is also important. Starting at about age 16, providers should assist youth and families in preparing for changes in decision-making when youth legally become adults at age 18. For some youth and families this may require referring them to legal resources about supported decision-making, and for others it may require obtaining their consent to involve parents/caregivers. In addition, transition planning involves inquiring about youth's preferences for transferring to adult specialty providers and assisting them in this process.

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Got Transition® is a program of National Alliance Logo The National Alliance to Advance Adolescent Health supported by U1TMC31756 HRSA/MCHB