(Pediatric, Family Medicine, and Med-Peds Providers)
(Family Medicine and Med-Peds Providers)
(Internal Medicine, Family Medicine, and Med-Peds Providers)
What is Health Care Transition?
Health care transition is the process of changing from a pediatric to an adult model of health care. The goal of transition is to optimize health and assist youth in reaching their full potential. To achieve this goal requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in care.
What are the Six Core Elements?
The Six Core Elements of Health Care Transition 2.0 define the basic components of health care transition support. These components include establishing a policy, tracking progress, administering transition readiness assessments, planning for adult care, transferring, and integrating into an adult practice.
There are three sets of customizable tools
available for different practice settings.
Aligned with the AAP/AAFP/ACP Clinical Report on Transition, the Six Core Elements are intended for use in primary and specialty settings. Originally developed in 2009, this updated version incorporates the results of several transition learning collaboratives, an examination of transition innovations in the US and abroad, and reviews by over 50 pediatric and adult health care professionals and youth and family experts.
Recommended Health Care Transition Timeline
Make youth and family aware of transition policy
Initiate health care transition planning
Prepare youth and parents for adult model of care and discuss transfer
Transition to adult model of care
Transfer care to adult medical home and/or specialists with transfer package
Integrate young adults into adult care
How do I implement the Six Core Elements?
As all transition approaches need to reflect the local capacity, a quality improvement (QI) approach has been a successful and efficient way to implement the Six Core Elements. To begin your QI process, assemble a team with pediatric and adult providers, clinic support staff, and youth and family consumers to review, customize, test and disseminate each of the core elements.
How can I assess my progress in implementing the Six Core Elements?
There are two options to consider: one is a qualitative self-assessment method (“Current Assessment of Health Care Transition Activities”) and the other is an objective scoring method (“Health Care Transition Process Measurement Tool”). Each tool can be conducted initially to offer a baseline measure and then repeated periodically to measure progress.
How can I assess my patients’ satisfaction with the transition process and make improvements to the transition process?
Following transition to adult care, practices can conduct anonymous consumer surveys with youth and/or parents. Sample “Health Care Transition Feedback Surveys” are available in each of the three sets of tools.