“The primary care provider plays an important role to . . . ensure that all young people with special health care needs have an identified health care professional who attends to the unique challenges of transition and assumes responsibility for current health care, care coordination and future health care planning.”
Source: A Consensus Statement on Health Care Transitions for Young Adults with Special Health Care Needs – AAP, AAFP & ACP (2002)
- Medical Home
Introduction - Medical Home Strategies
- Engage Families as Partners
- Identify Children & Youth with Special Health Care Needs
- Use Planned Encounters
- Improve Care Coordination:
Create Care Plans - Support Adolescent
Transitions - Collaborate with
Community Resources - Refine Coding &
Reimbursement Practices - Find Regional Centers
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Site last updated:
July 22, 2008
Wisconsin Resources
Wisconsin Transition Learning Collaborative
Transition guidelines
- Young adult/family checklist for transition (Word)
- Transition Readiness Checklist – Providers (Word)
- Transition Self-Assessment Tool (Word)
- 4-5 Years Before Leaving High School (PDF)
- 2-3 Years Before Leaving High School (PDF)
- 1 Year Before Leaving High School (PDF)
- How Health Care Differs in Adult World (Word)
Wisconsin Statewide Transition Initiative
Wisconsin Healthy & Ready to Work Project
National Resources
Healthy & Ready To Work National Resource Center
Transition Readiness Tools (Jacksonville Health and Transitions Service)
- for Caregivers (PDF)
- for Clients (PDF)
Treating Adolescents with HIV: Transitioning Care
Helping Young Adults with Mental Health Needs Transition into Adulthood (PDF)
Nine Easy Steps/Questions to Foster Successful Transition (Word)
Getting What You Need at Your Doctor’s Visit (Word)
Anticipatory Guidance/Family Assessment (PDF | link)
Improving Transition for Adolescents with Special Health Care Needs From Pediatric to Adult-Centered Care. Pediatrics. 2002
Sexuality of Children and Adolescents with Developmental Disabilities, Pediatrics. 2006
(PDF | link)
Transition to age-appropriate adult health care is a process, not a single event, involving the entire family and the youth’s team. Providers need to address health transitions with families and youth as early as possible, supporting skill building and increased independence as they reach school age, approach adolescence and move into adulthood. Below are some considerations when working with a youth in transition:
- Anticipate and facilitate the transition to adult health care;
- Discuss the adolescent's options for health insurance coverage with the family well before age 18 when many adolescents lose their family's coverage;
- Help families anticipate the need for legal decisions, prior to age18, regarding guardianship, health care power of attorney or other steps to continuity of care;
- Provide youth and families with information about sexuality to build skills in setting safe boundaries, developing good decision making skills and knowing when to tell a trusted adult about a concern;
- Connect families to resources that will assist the young person with the transition to community living.
Videos
A physician describes how parents helped guide the development of their transition care plan. A parent and son describe how they’ve approached skill building and responsibility sharing to support his independence and safety.
Medical Home Resources
This section has a wealth of transition care plans to use or adapt, including several condition-specific resources. The state and national Healthy & Ready To Work programs provide resources and training for transition. Wisconsin’s Statewide Transition Initiative Web site offers resource links for every county.