For Physicians & Professionals
Transitioning from one stage to the next across the life span is a challenge for children and youth with special health care
needs (CYSHCN), their families, and their providers. Each stage has different issues to address, but the common challenge
is finding new professionals and organizations that might be able to provide needed services during and after the transition.
For example, parents of young children often have a difficult time finding services once they age out of Early Intervention
(Part C) and before they enter Kindergarten. Similarly, teenagers and young adults have a difficult time finding internal
medicine or family practice physicians as they become too old to continue seeing their pediatricians. This page will provide
a brief overview of various transitions and link to more detailed information in the For Parents & Families
Birth to Three
Well-child visits provide the primary care provider with the opportunity to see infants and toddlers, from Early Services
, on a frequent basis and catch early developmental problems. The use of standardized Developmental Screening
tools and referrals to Early Intervention providers when infants do not pass screenings can help identify developmental delays
and initiate needed services. If the infant does not qualify for Early Intervention services, the Medical Home will play a
larger role in helping families minimize delays and find additional services in the community.
Hospital to Home/Community
After a hospitalization, the Medical Home can support the transition from Hospital to Home/Community
and school by providing the family with needed documents for the school, coordinating referrals for needed services, and
coordinating with the IEP team or school nurse to make sure educational and health needs are met.
Where to Find More Transition Information on the Portal
In addition to the content in the pages mentioned above, information about transition is included in many of the Diagnoses & Conditions
Modules. We encourage Medical Homes to explore the information provided on the Portal and Contact
us if there is additional information that would be helpful in supporting their patients and families.
Information & Support
Center for Health Care Transition Improvement, a national resource for improving health care transition supports for youth
moving into the adult health care system, for health care professionals, families, youth, and state policy makers. The Six
Core Elements of Health Care Transition 2.0 define the basic components of health care transition support.
American Academy of Pediatrics Transition Website
This website offers information on transitions from pediatric to adult health care for adolescents with special health care
For Parents and Patients
Help Me Grow Utah
Information service that connects families of young children to community resources; developmental screening tool provided
to parents; and monitoring of referrals to resources. Services are available in English and Spanish. Help Me Grow’s target
population is children ages 0-8 years-old who live in Utah.
Introduction. Improving transition for adolescents with special health care needs from pediatric to adult-centered health
2002;110(6 Pt 2):1301-3.
PubMed abstract / Full Text
Olsen DG, Swigonski NL.
Transition to adulthood: the important role of the pediatrician.
2004;113(3 Pt 1):e159-62.
PubMed abstract / Full Text
Cooley WC, Sagerman PJ.
Supporting the health care transition from adolescence to adulthood in the medical home.
|Content Last Updated: