Florida Youth to Adult Transition - FLY2AT

For Health Care Practitioners

Clinical Guidelines

  • in 2018, the AAP, AAFP, and ACP updated their original 2011 clinical report on health care transition. This updated clinical report, “Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home,” provides new practice-based quality improvement guidance on key elements of transition: planning, transfer, and integration into adult care. It also includes new recommendations pertaining to infrastructure, education and training, payment, and research.
  • Updated Six Core Elements of Health Care Transition 3.0:  Comprehensive tool packages from Got Transition 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. These packages include sample policies, registries, transition readiness/self-care assessments, condition fact sheets, medical summary and emergency care plans, transfer letters and checklists, young adult orientation material, care plans, feedback surveys and measurement approaches. Download the Six Core Elements and the supporting tool packages on the Got Transition web site here.
  • Step-by-Step Implementation Guides for the Six Core Elements: To help practices transform their HCT processes, Got Transition has developed practical step-by-step Implementation Guides dedicated to each core element. Got Transition recommends a quality improvement (QI) approach to incrementally incorporate the tools as a standard part of care, and these guides offer real world examples from practices utilizing the Six Core Elements. Got Transition offers background information on how to use the Implementation Guides, as well as a Quality Improvement Primer for those unfamiliar with the QI process.
  • Condition-Specific Tools from the American College of Physicians are available for the following subspecialties: general internal medicine (intellectual/developmental disabilities and physical disabilities), cardiology, endocrinology, gastroenterology, hematology, nephrology, and rheumatology.  The toolkit includes transition readiness assessments, self-care assessments, and medical summaries customized from Got Transition’s Six Core Elements.
  • Pathways to preparation, planning and transfer:

Education &  Training for Professionals

  • Coding and Reimbursement Tip Sheet.  Got Transition and the American Academy of Pediatrics developed a transition payment tip sheet to support the delivery of recommended transition services in pediatric and adult primary and specialty care settings. It provides a summary of alternative payment methodologies and comprehensive listing of transition-related CPT codes and corresponding Medicare fees (2020).
  • Letter Template to Payers Regarding Recognition of Codes Related to Pediatric to Adult Transition Services.  A letter template to payers requesting recognition of transition-related codes. Edit and personalize PDF, or copy and paste into a Word document to edit and personalize, from Got Transition (2017)

Transition Readiness Assessments, Checklists & Care Plans

  • TRAQ, Transition Readiness Assessment Tool. TRAQ is a validated, patient-centered questionnaire that providers and families can use to assess youths’ ability to make appointments, to understand their medications and to develop other skills needed for transition to adult care. It is designed to be self-administered and it takes less than 5 minutes for youth to fill it out. The questionnaire can also be filled out by caretakers to get their perspective on their youth’s transition skills. Use of this instrument has the potential to improve transition assessment and support and improve health outcomes during healthcare transition for youth with special health care needs. TRAQ is available in an excel file to input, score and aggregate results, or in PDF. Visit the East Tennessee State University web site to download the instrument and learn more.
  • TRAScore [© 2013 Mountain Area Health Education Center (MAHEC), Asheville, NC;  20-item assessment with automatic score calculation]
  • Brief Transition Checklist (ages 12 – 18+)
  • Transition Timeline (from Shriner’s Hospitals and University of Washington)

Medical Summary Forms

Condition-Specific Checklists & Care Plans

Autism Spectrum Disorders

Cornelia de Lange Syndrome

Cystic Fibrosis



Intellectual Disability/Developmental Disability  (ID/DD)

Metabolic Conditions

Sickle Cell Disease

  • The Sickle Cell Transition Curriculum (SCDTC) is a reference for healthcare practitioners, youth/young adults, and parents that includes practical age-specific guidelines for patients aged 12-25 with (from WISCH)

Spina Bifida

Service System Materials

Juvenile Justice

Secondary & Post-Secondary Education

Foster Care

Mental Health

Oral Health

  • Oral Health Florida
  • Florida Donated Dental Services (DDS) provides dental care to elderly, disabled and medically at-risk clients. One must be unable to pay for dental care and need extensive treatment (more than routine care).  Visit here to learn more and to apply for services.
  • Oral Health Sustainability Resource Center  (developed by Palm Beach State College)

Scholarly Publications

Other Resources