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
- Health Care Transition Summary (2 page summary to carry at all times)
- H.I. Doc (portable summary from State of New York)
- My Health Passport (English) and Mi Pasaporte de Salud (Spanish); designed by Florida Center for Inclusive Communities, University of South Florida, for persons with developmental disabilities)
- Electronic Care Plan (University of Wisconsin)
- Health Reports (Florida Center for Inclusive Communities)
Condition-Specific Checklists & Care Plans
Autism Spectrum Disorders
- Making Health Care Transition Work for Youth with Autism (2019, webinar from National Institute of Mental Health and Got Transition)
- Got Transition has published a new tip sheet with suggestions to help adult health care providers successfully integrate young adults with Autism Spectrum Disorder (ASD) into their practices.
- Autism Transition Resources (2013, Massachusetts General Hospital)
- Transition Training Toolbox of Resources (AUCD’s Interdisciplinary Technical Assistance Center on Autism and Developmental Disabilities search site, for 30 different transition related resources)
- Transition to Adult Health Care for Youth with Autism Spectrum Disorders (2012, Karen Kuhlthau, Massachusetts General Hospital)
- Autism Speaks: Transition Toolkit
- Individuals with autism often face extra challenges during procedures like physical examinations and blood draws due to communication deficits and sensory issues. Watch these brief presentations aimed at helping patients prepare for medical procedures. Print and share the video support handout from the Autism Research Institute.
Cornelia de Lange Syndrome
- Navigating Healthcare Transitions for Professionals (2016, from Cornelia de Lange Syndrome Foundation)
Cystic Fibrosis
- Moving On: Cystic Fibrosis (University of Wisconsin Madison)
Diabetes
- NDEP Transitions (National Diabetes Education Program web site)
- Sample Section 504 Plan for Diabetes (from American Diabetes Association)
HIV/AIDS
- HIV Clinical Resource (NY State and Johns Hopkins University)
Intellectual Disability/Developmental Disability (ID/DD)
- Integrating Young Adults with Intellectual and Developmental Disabilities into Your Practice, from Got Transition (2019)
- Healthy Transitions (New York State Institute for Health Transition Training)
-
FYI Transition (web-based learning on transition planning, career and post-secondary education planning, job development and support, health, and independent living)
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
- Spina Bifida Overview for Teachers (Fact sheet from the Spina Bifida Association)
Service System Materials
Juvenile Justice
Secondary & Post-Secondary Education
Foster Care
Mental Health
- Becoming An Adult: Challenges for those with Mental Health Conditions (Transitions RTC, 2011)
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)
- Adolescents (13-20 years)
- Adults (20-55 years)
Scholarly Publications
- How the Health System Overlooks Young Adults with Chronic Conditions (Stuart Butler, JAMA Health Forum, 2021)
Other Resources
- NAHIC (National Adolescent and Young Adult Health Information Center)
- Best Practices for Youth Participation in Team Planning
- AAMC: Matheny Medical Education