TRANSITION YOUTH FROM
PEDIATRIC TO ADULT
HEALTHCARE
A GUIDE FOR PROVIDERS
PURPOSE
• TO ASSIST PROVIDERS IN PREPARING TO
TRANSITION YOUTH TO ADULT HEALTHCARE
• TO FOLLOW GUIDELINES ESTABLISHED BY THE
NATIONAL HEALTH CARE TRANSITION CENTER
Children’s Healthcare of Atlanta
REFERENCE
• Griffin, A., Gilleland, J., Cummings, L., Johnson, A.,
Brailey, T.; New, T.; Eckman, J.; and Osunkwo, I.
(2013). Applying a Developmental-Ecological
Framework to Sickle Cell Disease Transition. Clinical
Practice in Pediatric Psychology, 1 (3) 250-263.
• THE NATIONAL HEALTH CARE TRANSITION CENTER,
(2011) Six core elements of health care transition.
Retrieved from:
http://www.gottransition.or/6-ccore-elements
Children’s Healthcare of Atlanta
TRANSITIONING: Six Core Elements
•
•
•
•
•
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Transition Policy
Transition Tracking and Monitoring
Transition Readiness Assessment
Transition Planning
Transfer of Care
Transfer Completion
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TRANSITIONING: Six Core Elements
1.
Should have a written transition guideline that is prominently displayed and discussed with
all patients and their parents/guardians regardless of age. The guideline should align with
Transitioning Patients to Adult Healthcare and state expectations and care process for
health care transition to adult care.
2.
Ensure all patients have a transition plan that is reviewed and completed regularly.
3.
Facilitate engagement and participation of transition team with patients and their
parents/guardians.
4.
Formal hand-off of patients to adult care providers by completing customized transition
health profile.
5.
Engage and educate parents/guardians to normalize the transition process to foster a team
approach for transition and beyond.
6.
Empower patients through transition to develop self-management skills and tools as
appropriate.
Children’s Healthcare of Atlanta
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Transition Resources
• Please visit the following transition website for
resources to assist in implementing the Six Core
Transition Elements.
http://www.gottransition.org/resources/
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SIX CORE ELEMENTS:
Transition Policy Example
• Guidelines
• Transition education and awareness may begin as
early as the age of 12 with patients achieving key
milestones up to the age of 21. Each individual and
their health care needs will be different. Specialties
should customize transition plans according to
patient’s health care needs to facilitate smooth
transitions.
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SIX CORE ELEMENTS
Transition Policy Example
• Guidelines
• By Ages 12 – 14: the pediatric provider should
– Introduce patients and their parents/guardians to transition guidelines
– Develop a transition plan in partnership with the patient and their
parents/guardians.
– The transition plan should document milestones and deadlines to
assure successful transition.
– Start the education and awareness process to ensure patients and
parents/guardians fully understand the transition goals and process
and medical condition(s) and interventions needed for continuum of
care. Introduce patients to all team members.
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SIX CORE ELEMENTS:
Transition Policy Example
• Guidelines
• By Ages 15 – 17: The patient and parents/guardians
should be empowered to take ownership of their
health care. The patient should be assigned a care
team. The care team should assist in coordination of
services to achieve a seamless transition. Legal
guardianship should be discussed with the provider
as considered appropriate.
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SIX CORE ELEMENTS:
Transition Policy Example
• Guidelines
• By Ages 18 – 20: At this pivotal point of transition,
the patient is considered an adult under the law.
Specific visits may be initiated to complete
milestones and address transition issues. A health
profile or necessary documents should be
completed for the patient to take to their adult care
provider on pre-transfer or first visit.
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SIX CORE ELEMENTS:
Transition Policy Example
• Guidelines
• By Age 21: Transition should be completed. Patients
and legal guardian will assume primary role as the
advocate for healthcare needs.
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SIX CORE ELEMENTS:
Transition Policy Example
• Provider expectations:
– A written transition guideline that is displayed and
discussed with all patients and their parents/guardians
regardless of age.
– All patients have a transition plan that is reviewed and
completed regularly.
– Facilitate engagement and participation with patients, and
participation of transition team with patients and their
parents/guardians.
Children’s Healthcare of Atlanta
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SIX CORE ELEMENTS:
Transition Policy Example
• Provider expectations:
– Formal hand-off of patients to adult care providers by
completing customized transition health profile.
– Engage and educate parents/guardians to normalize the
transition process to foster a team approach for transition
and beyond.
– Empower patients through transitions to develop selfmanagement skills and tools as appropriate.
Children’s Healthcare of Atlanta
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Developing a Transition Program
The following is an example of a comprehensive
transition program that covers all six of the core
elements from Got Transition:
https://dph.georgia.gov/sites/dph.georgia.gov/files/MCH
/CMS/steppingUPadultCARE.pdf
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Georgia Department of Public Health
http://dph.georgia.gov/transitioning-youth-adult-care
Georgia Department of Public Health
http://dph.georgia.gov/transitioning-youth-adult-care
Sickle Cell Knowledge
• Sickle Cell Transition E-Step Program is a great
interactive website for your teen patients to learn
sickle cell information. Pre- and Post-quizzes are
available to verify learning.
• http://www.stjude.org/stjude/v/index.jsp?vgnextoid
=cfc90d5c7533e310VgnVCM100000290115acRCRD&
vgnextchannel=ad590d5c7533e310VgnVCM1000002
90115acRCRD
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Transition Tracking and Monitoring
• Consider the following guide developed by “Got
Transition”:
http://www.gottransition.org/resourceGet.cfm?id=222
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TRANSITION PLAN: A TRACKING AND
MONITORING EXAMPLE
18 Steps to 18
This contract will explain what you should know before transltioning to an adult Sickle Cell program.
Steps
Date
Initiated
.
Date
Completed
I will have a primary doctor and will know the contact information.
I will have a hematologist and will know the contact information.
I will be able to name my medicines. I will know what they are for and how
much I take.
4.
I will take medicines as prescribed by my doctor.
5.
I will carry a back-up supply of medicines and an updated list of medicines with
me.
6.
I will call in my own medicine refills before I run out of meds.
7.
Review transition summary with pediatric hematologist. .
8. I will carry important medical phone numbers with me (pharmacy, hospital, Jab).
9. I will get labs as often as I am supposed to and I will know how often that is. I
will know the name of the lab center where I get Jabs done and the fax number
there.
' 10. I will have a written plan to keep my Insurance.
11. I will be able to schedule my own doctor's and clinic appointments.
12. I will meet with a Children's Healthcare financial counselor.
13. I will have physical activity at least 30 minutes per day/ 5 days per week.
14. I will graduate fr.om high school or receive my GED.
15. I will have a plan for school or work after high school graduation.
16. I will attend the age appropriate transition program.
17. I will maintain a healthy weight and body mass index (BMI).
18. Make and attend first appointment with adult hematologist.
Other additional steps:
1.
2.
3.
.
At each ch.m.c
..
V IS it,
. .
..
you will be g1ven some of the 18 steps to complete before the next chmc v1 s1 t•
***Your steps will be reviewed after every teen clinic visit.
With the help of my family, it is my responsibility to complete these steps. I agree to complete all18 steps before I
transition to an adult Sickle Cell clinic.
Patient Signature
Date
Parent/Gaurdian Signature
Date·
Sickle Cell Team Member's Signature
Date
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Transition Readiness Assessment Tool:
Examples
• Got Transition’s Assessment Tool
– http://www.gottransition.org/resourceGet.cfm?id=224
• University of Florida’s Assessment Tool
– http://www.hscj.ufl.edu/jaxhats/traq/documents/TRAQ5.0.pdf
• University of North Carolina’s Assessment Tool
– http://www.med.unc.edu/transition/files/trxansit-scale1-adolescent/view
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Transitioning: Six Core Elements
• Formal hand-off of patients to adult care providers
by completing customized transition health profile.
• Complete a transition summary for each patient at
age 17 that is updated throughout the year.
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SICKLE CELL TRANSITION SUMMARY
• http://www.gottransition.org/resourceGet.cfm?id=2
27
• http://www.floridahats.org/wpcontent/uploads/2010/03/HCT-Summary.pdf
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Thank You!