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Clinical Report: Transitions

The Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home clinical report is jointly authored by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP) and provides practical, detailed guidance on how to plan and execute better health care transitions for all patients. The Council on Children with Disabilities (COCWD) led the development of this document. A step-by-step algorithm, on how to plan and execute better health care transitions for all patients, is included.

Abstract: Optimal health care is achieved when each person, at every age, receives medically and developmentally appropriate care. The goal of a planned health care transition is to maximize lifelong functioning and well-being for all youth, including those who have special health care needs and those who do not. This process includes ensuring that high-quality, developmentally appropriate health care services are available in an uninterrupted manner as the person moves from adolescence to adulthood. A well-timed transition from child- to adult-oriented health care is specific to each person and ideally occurs between the ages of 18 and 21 years. Coordination of patient, family, and provider responsibilities enables youth to optimize their ability to assume adult roles and activities.

This clinical report represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence. It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it. Primary care physicians, nurse practitioners, and physician assistants, as well as medical subspecialists, are encouraged to adopt these materials and make this process specific to their settings and populations.

Resources: Transitions

Coding and Payment for Transitions
This tip sheet​ supports the delivery of recommended transition services in pediatric and adult primary and specialty care settings. It describes innovative payment methodologies with a listing of transition-related CPT codes with corresponding Medicare fees. A recent AAP News article, "Coding, payment options for pediatric to adult care transition services" provides further information.​

Center for Health Care Transition Improvement (Got Transition)
With funding support from the MCHB, Got Transition focuses on: 1) quality improvement spread using the Six Core Elements of Health Care Transition; 2) health care ​professional training; 3) youth and family engagement; 4) policy improvements; and 5) information dissemination.

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 3 sets of customizable tools available for different practice settings:

  1. Transitioning Youth to Adult Health Care Providers (Pediatric, Family Medicine, and Med-Ped​s Providers)

  2. Transitioning to an Adult Approach to Health Care Without Changing Providers (Family Medicine and Med-Peds Providers)

  3. Integrating Young Adults into Adult Health Care (Internal Medicine, Family Medicine, and Med-Peds Providers)

Transition QuickGuide on Health Care and Career Planning
Transition QuickGuide for youth and young adults (ages 12-30), including those with disabilities and chronic health conditions, has information about health insurance, self-care management, transition from pediatric to adult health care, decision-making, and career planning.

Tip Sheet for Integrating Young Adults with ID/DD into Practice
Tip sheet helps guide adult health care providers in receiving new young adult patients with intellectual and developmental disabilities (ID/DD) into their practice. It provides suggestions for preparing the office and staff for welcoming young adults with ID/DD. It offers tips for what to do before, during, and after the young adult’s first visit.

Starting a Transition Improvement Process
A practical set of steps for starting a transition improvement process has been compiled from lessons learned from improvement projects across the country. The sets can be used by pediatric, family medicine, and internal medicine primary care and specialty practices as well as by health systems, health plans, and payers in concert with the clinical tools and measurement resources available at Got Transition.

Web-Based Training and Transitions QI Project
The Transitioning Youth to Adult Health Care for Pediatric Providers course and quality improvement activity includes resources to improve care of transitioning youth: clinical guidelines, videos, skills building tools for youth, and QI tools. Learn how to use medical home and QI strategies to improve care of transitioning youth, especially CYSHCN. Maintenance of Certification (MOC) Part IV credit is available.

Special Report on America’s Young Adults
“America’s Young Adults” highlights a broad set of indicators on transition to adulthood. This report provides current data on the 18-24 year old population related to demographics, education, economic success, family support, civic/social/personal behavior, and health and safety.

Fact Sheets on ACA Provisions
4 fact sheets explain specific provisions of the ACA that benefit CYSHCN: Concurrent Care for Children; Habilitative Services; Health Home Programs and Coordinated Care; and Health Insurance Marketplace and Medicaid Coverage for Children with Disabilities.

Medical Home Interview Videos
Developed by the National Center for Medical Home Implementation

Web-Based Training and Transitions QI Project:
The Transitioning Youth to Adult Health Care for Pediatric Providers course and quality improvement activity includes resources to improve care of transitioning youth: clinical guidelines, videos, skills building tools for youth, and QI tools. Learn how to use medical home and QI strategies to improve care of transitioning youth, especially CYSHCN. Maintenance of Certification (MOC) Part IV credit is available.

Transitions Resources – 1 Page Document (Sept 2015)​

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