| Transitioning youth to adult health care providers (pediatric, family medicine, and med-peds providers) | Transitioning to an adult approach to health care without changing providers (family medicine and med-peds providers) | Integrating AYAs into adult health care (internal medicine, family medicine, and med-peds providers) |
| 1. Transition policy | 1. Transition policy | 1. AYA transition and care policy |
- Develop a transition policy/statement with input from youth and families that describes the practice's approach to transition, including privacy and consent information.
- Educate all staff about the practice's approach to transition, the policy/statement, the six core elements, and distinct roles of the youth, family, and pediatric and adult health care team in the transition process, taking into account cultural preferences.
- Post policy and share/discuss with youth and families, beginning at age 12 to 14, and regularly review as part of ongoing care.
| - Develop a transition policy/statement with input from youth/AYA and families that describes the practice's approach to transitioning to an adult approach to care at age 18, including privacy and consent information.
- Educate all staff about the practice's approach to transition, the policy/statement, the six core elements, and distinct roles of the youth, family, and health care team in the transition process, taking into account cultural preferences.
- Post policy and share/discuss with youth and families, beginning at age 12 to 14, and regularly review as part of ongoing care.
| - Develop a transition policy/statement with input from AYAs that describes the practice's approach to accepting and partnering with new AYAs, including privacy and consent information.
- Educate all staff about the practice's approach to transition, the policy/statement, the six core elements, and distinct roles of the AYA, family, and pediatric and adult health care team in the transition process, taking into account cultural preferences.
- Post policy and share/discuss with AYAs at first visit and regularly review as part of ongoing care.
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| 2. Transition tracking and monitoring | 2. Transition tracking and monitoring | 2. AYA tracking and monitoring |
- Establish criteria and process for identifying transitioning youth and enter their data into a registry.
- Utilize individual flow sheet or registry to track youth's transition progress with the six core elements.
- Incorporate the six core elements into clinical care process, using the electronic health record if possible.
| - Establish criteria and process for identifying transitioning youth/AYA and enter their data into a registry.
- Utilize individual flow sheet or registry to track youth/AYAs' transition progress with the six core elements.
- Incorporate the six core elements into clinical care process, using the electronic health record if possible.
| - Establish criteria and process for identifying transitioning AYAs until age 26 and enter their data into a registry.
- Utilize individual flow sheet or registry to track AYAs' completion of the six core elements.
- Incorporate the six core elements into clinical care process, using the electronic health record if possible.
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| 3. Transition readiness | 3. Transition readiness | 3. Transition readiness/orientation to adult practice |
- Conduct regular transition readiness assessments, beginning at age 14, to identify and discuss with youth and parent/caregiver their needs and goals in self-care.
- Jointly develop goals and prioritized actions with youth and parent/caregiver, and document regularly in a plan of care.
| - Conduct regular transition readiness assessments, beginning at age 14, to identify and discuss with youth and parent/caregiver their needs and goals in self-care.
- Jointly develop goals and prioritized actions with youth and parent/caregiver, and document regularly in a plan of care.
| - Identify and list adult providers within your practice interested in caring for AYAs.
- Establish a process to welcome and orient new AYAs into practice, including a description of available services.
- Provide youth-friendly online or written information about the practice and offer a "get-acquainted" appointment, if feasible.
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| 4. Transition planning | 4. Transition planning/integration into adult approach to care | 4. Transition planning/integration into adult practice |
- Develop and regularly update the plan of care, including readiness assessment findings, goals and prioritized actions, medical summary and emergency care plan, and, if needed, a condition fact sheet and legal documents.
- Prepare youth and parent/caregiver for adult approach to care at age 18, including legal changes in decision-making and privacy and consent, self-advocacy, and access to information.
- Determine level of need for decision-making supports for youth with intellectual challenges and make referrals to legal resources.
- Plan with youth/parent/caregiver for optimal timing of transfer. If both primary and subspecialty care are involved, discuss optimal timing for each.
- Obtain consent from youth/guardian for release of medical information.
- Assist youth in identifying an adult provider and communicate with selected provider about pending transfer of care.
- Provide linkages to insurance resources, self-care management information, and culturally appropriate community supports.
| - Develop and regularly update a plan of care, including readiness assessment findings, goals and prioritized actions, medical summary and emergency care plan, and, if needed, legal documents.
- Prepare youth and parent/caregiver for adult approach to care at age 18, including legal changes in decision-making and privacy and consent, self-advocacy, and access to information.
- Determine need for decision-making supports for youth with intellectual challenges and make referrals to legal resources.
- Plan with youth and parent/caregiver for optimal timing of transfer from pediatric to adult specialty care.
- Obtain consent from youth/guardian for release of medical information.
- Provide linkages to insurance resources, self-care management information, and culturally appropriate community supports.
| - Communicate with AYA's pediatric provider(s) and arrange for consultation assistance, if needed.
- Prior to first visit, ensure receipt of transfer package (final transition readiness assessment, plan of care with transition goals and pending actions, medical summary and emergency care plan, and, if needed, legal documents, condition fact sheet, and additional provider records).
- Make previsit appointment reminder call welcoming new AYA and identifying any special needs and preferences.
- Provide linkages to insurance resources, self-care management information, and culturally appropriate community supports.
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| 5. Transfer of care | 5. Transfer to adult approach to care | 5. Transfer of care/initial visit |
- Confirm date of first adult provider appointment.
- Transfer AYA when his/her condition is stable.
- Complete transfer package, including final transition readiness assessment, plan of care with transition goals and pending actions, medical summary and emergency care plan, and, if needed, legal documents, condition fact sheet, and additional provider records.
- Prepare letter with transfer package, send to adult practice, and confirm adult practice's receipt of transfer package.
- Confirm with adult provider the pediatric provider's responsibility for care until AYA is seen in adult setting.
| - Address any concerns that AYA has about transferring to adult approach to care. Clarify adult approach to care, including shared decision-making, privacy and consent, access to information, adherence to care, and preferred methods of communication, including attending to health literacy needs.
- Conduct self-care assessment (transition readiness assessment) if not recently completed and discuss needed self-care skills.
- Review young adult's health priorities as part of ongoing plan of care.
- Continue to update and share portable medical summary and emergency care plan.
| - Prepare for initial visit by reviewing transfer package with appropriate team members.
- Address any concerns that AYA has about transferring to adult approach to care. Clarify approach to adult care, including shared decision-making, privacy and consent, access to information, adherence to care, and preferred methods of communication, including attending to health literacy needs.
- Conduct self-care assessment (transition readiness assessment) if not recently completed and discuss the AYA's needs and goals in self-care.
- Review AYA's health priorities as part of their plan of care.
- Update and share portable medical summary and emergency care plan.
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| 6. Transfer completion | 6. Transfer completion/ongoing care | 6. Transfer completion/ongoing care |
- Contact AYA and parent/caregiver three to six months after last pediatric visit to confirm transfer of responsibilities to adult practice and elicit feedback on experience with transition process.
- Communicate with adult practice confirming completion of transfer and offer consultation assistance, as needed.
- Build ongoing and collaborative partnerships with adult primary and specialty care providers.
| - Assist AYA to connect with adult specialists and other support services, as needed.
- Continue with ongoing care management tailored to each AYA.
- Elicit feedback from AYA to assess experience with adult health care.
- Build ongoing and collaborative partnerships with specialty care providers.
| - Communicate with pediatric practice confirming transfer into adult practice and consult with pediatric provider(s), as needed.
- Assist AYA to connect with adult specialists and other support services, as needed.
- Continue with ongoing care management tailored to each AYA.
- Elicit feedback from AYA to assess experience with adult health care.
- Build ongoing and collaborative partnerships with pediatric primary and specialty care providers.
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