“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)
Transition Resources - Children's Hospital of Wisconsin (link)
Transition Curriculum & Guidebooks - Waisman Resource Center (link)
Pediatric Pulmonary Center, University of Wisconsin Madison (link)
Southeast Regional Center for CYSHCN
Care Planning Tools
Guardianship Resources - The Arc-Dane County (link)
University of Washington
The Physician's Guide to Caring for Children with Disabilities and Chronic Conditions: Care Summaries and Plans (link)
Planning for Health Care Transitions: Results from the 2005-2006 National Survey of Children With Special Health Care Needs, Pediatrics. 2009 (link)
Sexuality of Children and Adolescents with Developmental Disabilities, Pediatrics. 2006
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:
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.