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Transition for Health Care Providers

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New AAP/AAFP/ACP Clinical Report on Health Care Transition
  • This clinical report provides a consensus on activities to support the implementation of health care transition planning for youth with and without special health care needs. It describes a series of activities designed to ensure that developmentally appropriate health care services are available to patients moving from adolescence to adulthood. The clinical report provides a clear time line, beginning at 12 years of age, to assist providers in implementing specific activities in transition: discussing the medical home transition policy; initiating a transition plan; reviewing/updating the transition plan; and implementing an adult care model. It also includes an algorithm that specifies the protocol for managing the transition process, helps providers implement the transition process, and provides a transition structure for patients and their families. The algorithm, described below, includes a branch with guidelines for transitioning youth with special health care needs who require chronic condition management.

  • The Health Care Transition Planning Algorithm comes from the clinical report “Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home.” It outlines a step-by-step decision-making process for transitioning youth, beginning at age 12 and culminating in actual transition between the ages of 18 -21. It includes branches for youth with and without special health care needs.

Transition Practice Tools from the Center for Health Care Transition Improvement
  • To implement the Algorithm, Got Transition created the “Six Core Elements of Health Care Transition 2.0" based off the AAP/AAFP/ACP clinic report. Comprehensive tool packages are available for three transition processes: 1) transitioning youth to adult health care providers, 2) transitioning youth to an adult approach to health care without changing providers and 3) integrating youth into adult health care.

  • Six Core Elements - This is a one-page PDF file that describes the three distinct packages of the Six Core Elements 2.0.

  • Six Core Elements with Downloadable Packages - This is a link to a page on Got Transition’s website which has downloadable packages for the corresponding tools and resources in each of the Six Core Elements. Those tools include examples of a registry for pediatric or adult health care settings, readiness assessments, Health Care Transition Action Plans, Transfer of Care checklists, and more.

Evaluation of Health Care Transition
  • There are evaluation tools within each of the three packages that allow practices to assess their progress in implementing each of the six core elements of health care transition. The indices rank the level of implementation for a health care setting, from Level 1 (Basic) to Level 4 (Comprehensive) while Health Care Transition Measurement Tool provides an objective method for scoring the level of health care transition efforts for each site.

DC Transition Learning Collaborative
  • The District of Columbia is the first site in the country to design, implement, and evaluate the new health care transition recommendations from the AAP/AAFP/ACP. With funding support from the DC Community Health Administration, The National Alliance to Advance Adolescent Health (Peggy McManus and Patience White, Co-Principal Investigators) is working with 3 pediatric primary care sites and 2 adult sites to transition youth with special needs from pediatric to adult health care. The 5 sites include Children’s National Medical Center’s Adolescent Clinic and their Adams Morgan Children’s Health Center, Georgetown’s Adolescent Clinic, Howard’s Family Medicine Clinic, and George Washington’s Internal Medicine Clinic. Each of these sites has selected a lead physician, care coordinator, and consumer (parent or young adult) to implement transition quality improvement activities. Over the past year, these sites have been involved in intensive training sessions, monthly coaching calls, and on-site technical assistance with training support from the National Health Care Transition Center. Continued support to these sites will be continued over the coming year as they incorporate transition practice improvements into clinical systems and expand training opportunities to health care professionals and residents working in their sites.

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