Transition Issues

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 tab/section.

Well-child visits provide the primary care provider with the opportunity to see infants and toddlers, from Birth to Three, 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.

As children begin to access services from the local school system, the Medical Home will play in important role as the single, consistent service provider. Students will change schools as they move from Early Intervention To Preschool, To Kindergarten & Elementary School, To Middle School, and To High School. The Medical Home can support students by providing documentation of medical diagnoses and needs. The Medical Home can also assist the family helping the student become more independent, manage his or her health needs, and discuss issues that are not addressed in schools.

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.

As teenagers transition To College and Transition to Adulthood the Medical Home may still play a role in providing needed documentation of disabilities for Guardianship/Estate Planning or accomodations in college classes, but the role shifts to helping the youth become more independent and learn to manage his or her own health care. One of the biggest challenges for young adults is Finding Adult Health Care. The pediatric Medical Home can help by recommending adult care providers that have experience caring for CYSHCN and by providing information to the new adult Medical Home to ease the transition process. The Medical Home can also help the young adult find additional resources in the community for Employment/Daytime Activities, Independent Living, Travel/Transportation, Genetic Counseling, and Health Insurance/Financial Aids.

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.