I want to develop a Care Transition Team. Great! Medical homes are perfect for developing a Care Transition Team. We provide simple, step-by-step recommendations and tools for starting a care transition program for CYSHCN in your medical home. Youth and their families work in partnership with you, the health care provider, to assure that they are able to live as independently as possible as adults. The following suggestions align with the recommendations of the American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, and the Bureau of Maternal and Child Health.
First, Gather a Team (PDF | Word). Be sure to include Champions! Champions help drive successful CYSHCN care transition initiatives by increasing awareness of the importance of facilitating transition, building support among leadership, providers, and staff, and monitoring the outcomes of care transition. It is helpful to have at least two champions to help ensure continued leadership should staff change.
Then, decide on Roles and Responsibilities (PDF| Word)
Think about what Tools you’ll need to facilitate care transition.There are many care transition tools available on this website, but each medical home has different patients, needs, priorities, and resources. Determine which tools have the best chance of leading to successful care transition in your practice.
Consider Implementation Factors. Develop a timeline, list of responsibilities, a budget, and a schedule for team meetings. You should consider your institution’s unique characteristics, needs, and resources, and think about specific items—such as costs for supplies and staff time— needed to carry out well facilitated care transition. For instance, can existing resources and workflows be adapted to meet the needs of the CYSHCN transitioning to adult care, or will new materials or procedures be needed? A sample meeting agenda (PDF | Word) can be used to guide team discussion and planning.
Communicate the new procedures to staff in a clear, easy-to-understand manner. Include information about the timeline for implementing the program and include a copy of the policies or procedures. Depending on the scope of the new procedures, training for staff and prescribing clinicians may also be needed.
I’ve got a Team. Now what? The American Academy of Pediatrics, American Academy of Family Physicians and American College of Physicians recommend that transition planning begin by age 12.
Providers can help patients plan for transition in a variety of ways:
- Discuss whether and when changing providers is appropriate and assist youth and their families in locating providers for adult clients as needed.
- Explain changes that occur in adolescence through adulthood and how a youth’s condition can affect those changes.
- Talk to youth and their families about changes to consent and confidentiality.
- Encourage youth to take control during their appointments and begin to see them without their parents/caregivers, as appropriate.
- Ensure that youth are knowledgeable about their conditions, medications, supplies, and health history.
- Discuss any changes in insurance and how they may affect the availability of providers and services.
You can select any of these following tools based on the ages of the CYSHCN in your practice.
Early Adolescence (PDF) Middle Adolescence (PDF) Late Adolescence (PDF ) Early Adulthood (PDF )
What then? Transitioning CYSHCN from pediatric to adults care is a patient-centered, lifelong process that helps youth with special health care needs and their families prepare for the move from childhood to adulthood. Follow-up after transfer of care. It is essential to confirm your patient made the transition from pediatric to adult care.
[Pediatrics, 2011]
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The National Alliance to Advance Adolescent Health |
University of California, San Francisco |
