Medical Home Portal - Transition Issues

"...Transition is a process, not an event. The actual process should be gradual, occurring in harmony with adolescent and family development. While there is not one current model, whenever it occurs, communication among pediatric and adult providers, parents and youth is critical." [National Dissemination Center for Children with Disabilities.]

Transition for children & youth with special health care needs

Transition for children with special health care needs is a continuum of changes (see graphic below), including moves from Hospital to Home, Home to School, School to School, Hospital to School, School to Work or College, and from Pediatric to Adult Health Care. Each transition is an opportunity to help the child and family gain the skills to optimize success and manage future transitions. This section provides information to help parents, providers, and children (younger or older) deal with the changes during these transition periods.

The Medical Home, as source of ongoing comprehensive care, is an ideal place to address these issues and should include transition planning as part of care throughout the child's life. The more a child understands about his/her own condition and needs, the better equipped she/he will be to attain increasing independence as he approaches adulthood.

How can health care providers help with transitions?

By understanding and anticipating the transitions ahead for patients, particularly those with special health care needs, physicians can engage patients and families in discussion and planning well in advance of the transition. By knowing available resources, physicians can collaborate with or refer families to key professionals, organizations, and services in the community and schools to assist in transitions and planning for them. Physicians' unique knowledge and valuable perspectives on the impact of health problems on emotional/developmental issues, social interactions, performance in school, vocational/educational options, and independent living make them vital to the transition process.

According to Olsen, there are three transition competencies that pediatricians and residents should practice:

developing practices that encourage the child/youth/young adult to accept responsibility for his or her own health care
planning for the future with families
linking families (including youths and young adults) to share information and experiences [Olsen: 2004]

To develop a Life Plan: begin with the end goals in mind

This section is organized into various categories of transition to allow access to important information from many different starting points, including the child's age and specific needs. No matter what their ability, children, youth, and adults with special health care needs can all benefit from a collaborative and supportive effort toward making transitions as smooth as possible.

Resources

Information & Support

For Professionals

American Academy of Pediatrics Transition Website
Information on transitions from pediatric to adult health care for adolescents with special health care needs.

Respecting the Young Adult Patient Video
The Young Adult Advisory Committee (YAC) for the Utah Medical Home - Integrated Services Project (UISP) provided tips for doctors when transitioning youth with disabilities to adult care services at the 2007 UISP/UPIQ Learning Session.

For Parents and Patients

Transition Tips for Parents of Newborns or Newly Diagnosed Children with Disabilities ( PDF Document 483 KB)
This pamphlet developed by Shriners Hospital for Children, also called A New Start, provides information for parents on coping, staying strong, building hope, utilizing resources, and using health care efficiently.

Transition Tips for Young Adults ( PDF Document 348 KB)
This pamphlet developed by Shriners Hospital for Children, also called Moving On, provides information for young adults on moving to adult health care; paying for health care; preparing for the future; getting around in the community; becoming more independent; and resources and websites.

Transition Tips for Parents of Young Adults with Disabilities ( PDF Document 346 KB)
This pamphlet developed by Shriners Hospital for Children, also called Moving On, provides information for parents on letting go; assisting young adults in becoming more independent; helping young adults find health insurance; helping young adults transition to adult health care; guardianship issues; and resources and websites.

Transition Timeline from the Utah School for the Deaf and Blind ( PDF Document 1.1 MB)
The timeline and information on this linked page provide parents, children, adolescents, and young adults with helpful hints about the many transitions from birth through the young adult years.

Becoming Leaders for Tomorrow
This Project, from the Center for Persons with Disabilities at Utah State University, provides transition and leadership training information for youth and young adults with disabilities.

Transitioning to Adulthood for Youth and Young Adults Brochure ( PDF Document 67 KB)
Tri-fold brochure for youth and young adults with special health care needs as they prepare to transition to adulthood.

Transition Information for Parents and Medical Providers Brochure ( PDF Document 67 KB)
Tri-fold brochure for parents and medical providers of youth and young adults with special health care needs as they assist in transitioning youth to adulthood.

Authors

Author:

Gina Pola-Money, 12/2005

Reviewing Author:

Alfred Romeo RN, PhD, 7/2008

Content Last Updated:

11/2008

Page Bibliography

Olsen DG, Swigonski NL.
Transition to adulthood: the important role of the pediatrician.
Pediatrics. 2004;113(3 Pt 1):e159-62. PubMed abstract