State Strategies and Examples

• Illinois: The state’s Statute on Transition Planning includes language related to health: “Independent living skills may include, without limitation: personal hygiene, health care, fitness, food preparation and nutrition, home management and safety, dressing and clothing care, financial management and wellness, self-esteem, self-advocacy, self-determination, community living, housing options, public safety, leisure and recreation, and transportation.” 
• Texas: The state’s Education Code includes facilitating referrals to services such as a waiver program and supported decision-making: “The commissioner shall by rule adopt procedures for compliance with federal requirements related to transition services for students enrolled in special education programs…(9) appropriate circumstances for facilitating a referral of a student or the student’s parents to a governmental agency for services or public benefits, including a referral to a government agency to place the student on a waiting list for public benefits available to the student, such as a waiver program….(10) The use and availability of appropriate: (A) supplementary aids, services, curricula, and other opportunities to assist the student in developing decision-making skills; and (B) supports and services to foster the student’s independence and self-determination, including a supported decision-making agreement.”

• Hawaii: The state’s Department of Health's Children with Special Health Care Needs Branch staff participate in monthly Hawaii Interagency Local Youth Network of Care meetings which includes representatives from state agencies who are involved with youth services. Discussions are related to island-specific issues, such as child welfare, health insurance, and special education.
• Illinois: The state’s Department of Rehabilitation Services is responsible for coordinating and sustaining local Transition Planning Committees (TPCs). These Committees identify existing resources and unmet needs, facilitate an ongoing exchange of information, and develop local customer training programs. Transition Planning Committees are a consortium of local members of schools, agencies, not-for-profit organizations, parents of children with disabilities, students with disabilities, and other stakeholders that band together to improve the transition life-cycle from high school to a successful adult life. At several meetings, Title V’s Division of Specialized Care for Children (DSCC) offers information and resources on the transition to adulthood and connections to the DSCC. They also provide trainings/presentations on DSCC programs and HCT for youth/young adults with special health care needs to several groups and to youth and families supported by the Transition Planning Committees. See Appendix B for more details.
• Michigan: The state’s Children's Special Health Care Services serves as the lead for a Transition Advisory Council, which consists of representation from all transition systems, as well as young adults and parents/caregivers. The advisory council will assist in developing strategies to streamline transition processes across the state and to create transition resources and trainings to assist youth and families with navigating the different systems.
•  Minnesota: The Dakota County Community Transition Interagency Committee serves nine school districts to promote effective transition services through community collaboration. Got Transition presented on HCT to their CTIC partner schools and agencies. The Committee’s website features a “Health & Wellness” section that connects families to the Independent School District 917 Health Services Department and providers, as well as information on student illness policies, immunizations, medication at schools, health-related services billing, and their Health, Wellness, and Safety Committee.
• Oregon: The state’s Title V CYSHCN staff are partnering with the Oregon Health Authority, Department of Education, and Department of Human Services to support improved Medicaid billing within school settings, including for HCT-related services. As part of these efforts, the Title V CYSHCN program’s Health and Education Project Manager now serves as a member of the School Medicaid Advisory Committee

• Illinois: The state’s Transition Study Group, a collaborative effort between three state organizations including the Illinois Center for Transition and Work, Illinois State Board of Education, and Illinois Department of Human Services the Division of Rehabilitation Services created a School-to-Work Transition Guide that mentions health under “Measurable Postsecondary Goals/Outcomes Statements” (page 11) and under “How Students Can Participate in their IEP/Transition Planning Meeting” (page 15).
• Michigan: The state’s Children’s Special Health Care Services Transition Specialist is part of a state interagency transition committee that focuses on improving coordination between secondary education and vocational rehabilitation for students with an IEP. The committee created A Guide to Transition from Special Education into Adulthood which includes a section on “Health” (page 33) and is available on multiple state agency websites.
• Minnesota: The state’s Title V Children and Youth with Special Health Needs and Disabilities program at the Minnesota Department of Health contributed to the development of the Minnesota Youth in Transition Framework and Toolkit—a cross-agency resource designed to help professionals support young people as they move from school-based to adult systems. The Department’s involvement ensured that health care was explicitly included as part of transition planning, with integrated tools from Charting the LifeCourse and Got Transition that help youth assess HCT readiness and manage their own health care. By embedding these materials into a statewide resource used by multiple agencies, Minnesota created a sustainable way to keep HCT visible in cross-system planning.

• Wisconsin: The state’s Interagency Agreement on Transition includes the Department of Public Instruction, Department of Workforce Development, Division of Vocational Rehabilitation, and the Department of Health Services, who have the primary responsibility for providing services to students and youth with disabilities. The 2020 update includes information on HCT and resources for the three agencies to use. In 2024, the Youth Health Transition Initiative was invited to join the interagency team that works on implementing Competitive Integrated Employment: Act 178.

Got Transition Tools: 

• Readiness Assessment: Using a HCT readiness assessment customized for students in special education with an IEP can start the process of understanding the health care skill needs of a student. This can be completed by the student or together with a parent/caregiver. Got Transition’s Readiness Assessment can be used and modified for this purpose. Click here for the Spanish version.
• Setting HCT Goals: HCT Goals can be added to an IEP transition plan based on the skill needs from the Readiness Assessment. Sample HCT goals can be found here. 

• Oregon: The state’s Title V CYSHCN program is working with both school nurses and special education case managers about the importance of considering health as a best practice when creating and reviewing IEPs. The program is working to strengthen partnerships between the local public health nurse home visiting programs (nurses and community health workers) and schools to support HCT. This includes exploring the use of shared care planning to facilitate HCT in schools.
• Vermont: The Vermont Graduation Readiness Tool and training video (“Graduation Readiness Tool - Training 12.17.24”) were created by the Student Support Coordinator. To support health, the state’s Department for CSHN asked that two questions be included in the Tool: “Does this student have a medical coordinator/medical home?”; and “Has the student’s medical home coordinator been invited to the IEP transition plan meetings?”.

• Wisconsin: The state’s Title V team joined the Wisconsin Youth Health Transition Initiative, the Transition Improvement Grant, and Got Transition to add two HCT questions to the annual Indicator 14 survey for families: “Since leaving high school, have you taken responsibility for your own health care?”; and “Which of the following things have you done to take responsibility for your own health care?”. The Title V program paid for the survey to be updated with these questions.

• Florida: An ongoing relationship was established between the state’s Title V CYSHCN Program and the state’s transition center, Project 10: Transition Education Network. Title V staff provided recommendations on including information about health care transition on the Project 10 website.
• Hawaii: In the state’s Post-Secondary Transition Handbook for educators, “health care needs” is listed as a sample item to consider under types of information that should be gathered for the transition assessments (page 22) while a section on informal assessments lists “health issues” as a specialty area that would be helpful for transition planning (page 24). See Appendix C for the full handbook.
• Wisconsin: In the state’s Transition Programming Beyond Age 18 Guide, the state’s Title V Program added a section on Healthcare (page 13) under Individualized Student Transition Planning in collaboration with the Beyond Age 18 Programming lead. The section highlights health considerations for the IEP team as well as HCT resources.
• Wisconsin: HCT resources were added to the state’s Department of Public Instruction website section “Resources for Health and Safety for Students with Disabilities” in collaboration with the Department’s Special Education team.

• Oregon: To better align with statewide efforts to integrate health and education, the state’s Title V CYSHCN team hired an education specialist with a background in special education to support these systems, with an emphasis on supporting HCT in the schools. The creation of a Health and Education Project Manager was built into the strategic plan to support this effort. See Appendix D for the position’s job description.

• Florida: Staff from the state’s Title V CYSHCN Program, along with a statewide workgroup of family leaders and interdisciplinary professionals from education, non-profit, and health care organizations, co-designed and developed a professional training course on whole person transition planning with a focus on HCT. The free online course consists of four short training modules and is publicly available at the Division of Children’s Medical Services website. One of the training modules covers Exceptional Student Education and the IEP process and supports the inclusion of health care transition within the IEP. The website that houses the training course, and the course itself, are sustained through consistent review and updates of the site and the companion resource materials.
• Oregon: Title V CYSHCN staff present on the process of incorporating HCT into IEPs at the statewide conferences on special education. Staff contacted transition network facilitators from across the state to build awareness around HCT in schools. This led to additional presentations for several regions and programs around HCT in IEPs and how schools can support the HCT process for CYSHCN.
• Vermont: CSHN’s Health Systems Team has a member on the Planning Committee for the annual statewide Core Conference, which is for Core team members (state employees from a variety of programs that have work aligned with transitioning to adulthood, special educators, service providers, etc.). Each Core team has different members, depending upon the location and that community’s services. The 2025 Core Conference had two breakout sessions about transitioning from pediatric medicine to adult services. CSHN staff participate in most of the 12 local Core teams. Local Core Transition Teams meet regularly throughout the school year to identify interagency collaborations to help school districts with student centered planning.
• Virginia: Virginia Commonwealth University produced a guide for teachers around critical transitions for students on SSI who reach their eighteenth birthday and will experience a disability redetermination.

• Florida: The state’s Title V CYSHCN Program staff present HCT workshops at various events with family and youth attendees. For example, the state holds one of the largest disability-related conferences in the country each June, the Annual Family Café.  HCT workshops address partnering with school staff on including HCT assessments and goals within students’ IEPs, to support whole person transition planning.
• Oregon: The state’s Family to Family Health Information Center is co-located with the Title V CYSHCN program. The Center’s staff collaborated with the state’s Parent Training and Information Center (FACT Oregon) to create a training for families on how to integrate HCT concepts into the IEP and why it is important to do so.
• Wisconsin: Each year the state’s Family Voices leads the Circles of Life Conference for families of children with special health care needs and disabilities. The conference draws hundreds of attendees. Two main workshops on HCT have been presented a number of times (in English and in Spanish). The “Bridging the Gap” workshop has a section on including health care in IEPs. Youth and family were included as co-presenters.

• Florida: Staff from the state’s Title V CYSHCN Program submitted proposals that were accepted and presented workshops on HCT at the annual Visions state conference hosted by the Florida Division of Career Development and Transition. The conference is for educational professionals within the Exceptional Student Education workforce. The workshop addressed recommendations to include HCT assessments and goals within students’ IEP Plans, to support whole person transition planning.
• Hawaii: The state’s Department of Health CSHN Branch participates in the annual “Footsteps to Transition” fairs, which are conducted on all islands and are targeted towards students/their families in special education. The fairs feature presentation on transition topics. There is also resource table of agencies and community-based organizations.
• Illinois: The Illinois Statewide Transition Conference highlights best practices for promoting effective, person-centered transition planning that prepares youth with disabilities for all aspects of adult life. The conference is in its 20th year. Doctors and experts on the transition to adult health care have presented for the health track section of the conference for several years. The health track focuses on the transition to adult health care for youth and young adults with disabilities and, for example, has included an introduction to HCT, engaging adult providers in HCT, managing mental health with a disability and a special panel on HCT.
• Oregon: Title V CYSHCN staff presented at the Oregon Statewide Transition Conference on the importance of addressing HCT in schools and the process of incorporating HCT into transition IEPs.
• Wisconsin: Since 2017, through a state Title V grantee, a breakout session including HCT has been presented at the Annual Transition Conference many times, with a focus on incorporating HCT into the student's Post-Secondary Transition Plan (PTP). 

• Georgia: The state’s Title V CYSHCN program partners with families and youth by providing HCT resources, educational workshops, and peer support through collaborations with Parent to Parent of Georgia and community partners. Youth engagement is amplified through the Georgia Youth Healthcare Leaders Council and the GA STEPS Up workgroup, where youth contribute to projects and leadership activities. Dedicated CYSHCN program staff, as well as incentives for youth and family leaders to ensure their voices are supported and embedded in program efforts. When requested, some workshops are in partnership with a specific special education counterpart (Transition Specialist or Parent Mentor). 
• Minnesota: The state’s Title V CYSHN program supports family engagement in HCT through partnerships with family-led organizations such as Family Voices of Minnesota and PACER Center. These partners provide education and peer support for families of youth with special health needs and disabilities, helping caregivers understand transition planning, supported decision-making, and self-advocacy. They offer a range of trainings and resources on topics such as health and health care. Ongoing collaboration through these networks makes this approach sustainable and ensures that information and tools continue reaching families statewide.
• Oregon: The state’s Title V CYSHN program produced a parent interview video and accompanying facilitated discussion templates to address specific practices, including HCT, integration of health into education settings and cross-systems care coordination. The model has been effective in building partnerships and, to date, initiating a quality improvement project with school nurses in one school district.
• Vermont: Vermont Family Network provided two sessions at their annual conference in March 2025. “Care Coordination 101” discussed fundamentals of coordinating care among multiple providers. “Transition from Pediatrics to Adulthood” addressed how to facilitate the change from pediatric to adult services effectively and included parts that linked to special education. The sessions were open to the public, educators, families, and medical professionals.
• Wisconsin: Workshops for families were provided through Wisconsin Family Ties, an affiliate of the National Federation of Families, on HCT in the Postsecondary Transition Plan with a focus on mental health, integrated transition planning, and Navigating Transition Together.

• Minnesota: The state’s Title V CYSHN program partnered with staff on the Department of Health’s Adolescent and School Health team to host a special-interest group of school nurses focused on HCT. This informal community of learning met monthly to collaborate and explore ways to support students with medical needs and disabilities in school settings. Guided by the National Association of School Nurses’ position statement on transition planning, sessions covered topics such as health-related goals within IEPs, medication management, and connections to community resources including Disability Hub MN, Centers for Independent Living, the Refugee Health Network, and Gillette Children’s Specialty Health Care. The initiative built statewide awareness among school nursing leaders and informed future integration of transition planning in school practice.
• Oregon: The Health and Education Project Manager meet regularly with the state’s School Nurse Consultant, school district nurses, representatives from the state’s Adolescent and School Health Program and School Based Health Centers to strengthen systems of care for CYSHCN in educational settings. The Title V CYSHCN program has leveraged these relationships to build awareness around the importance of addressing HCT at school. Staff provided educational materials about HCT at the state’s School Nurse Convention and presented to small groups of nurses about their role in HCT. Staff also regularly partner with the state’s State School Nurse Consultant and the director of the state’s School Nurse Association to explore the specific skills that can be taught to students to support HCT.
• Oregon: The state’s Title V CYSHCN program staff are working to increase the education system’s ability to identify CYSHCN in schools. This includes identifying at risk students not on an IEP or 504 but who still need support and care coordination (such as help with HCT). 
• Vermont: Title V CYSHCN staff continue to work with school nurse liaisons to build awareness of the importance of addressing HCT for students on IEPs. Several statewide organizations work with staff to create a resource for school nurses about medically complex students transitioning to adulthood planning.
• Wisconsin: The state collaborated with the Department of Public Instruction’s School Nursing and Health Services Consultant to provide education and resources for school nurses to support their important role in HCT. A website was co-designed, which provided articles for a regular email newsletter to school nurses, and exhibited and presented at a number of statewide Wisconsin Association of School Nurses conferences.

• Vermont: The state’s Core Transition Teams are facilitated by HireAbility Transition Coordinators. The Core Transition Teams include state employees from a variety of programs that have work aligned with transitioning to adulthood, special educators, service providers, college reps. HireAbility is the statewide vocational rehab program. CSHN attends meetings and assists with team efforts or collaboration.

• Florida: Staff from the state’s Title V CYSHCN Program have built a relationship with the Florida Independent Living Foundation, which hosts a week-long “Youth Leadership Forum” for in-state high school students with disabilities. Title V staff have presented workshops on HCT to the youth attendees at this annual event and addressed recommendations for including health care transition assessments and goals within the students’ IEPs to support whole person transition planning.