Roles of the Medical Home in Transition

  • Partner with the youth, family, and school to encourage independence from the time of diagnosis.
  • Share pertinent health information with the school team.
  • Ensure that the young person understands their disease, self-care, medications and side effects.
  • Communicate with the school to include self-management of the disease and medications as part of the transition IEP/504/transition plan. See Education and Schools.
  • Communicate possible modifications based on health considerations with the family, youth, and transition team.
  • Encourage the family to actively participate in the IEP/transition planning.
  • Focus on strengths, abilities, and the youths' career goals.
  • Promote habits of good health.
  • Encourage activities that promote responsibility and self-reliance such as money management, laundry, transportation, etc.
  • Teach where and when to ask for help.
  • Have resources readily available on: vocational options, schools, employment, and independent living. See Services Directory.
  • Have a list of college disability offices available. See To College.
For more information, see the AAP statement from the Committee on Children with Disabilities "The Role of the Pediatrician in Transitioning Children and Adolescents With Developmental Disabilities and Chronic Illnesses From School to Work or College." [American: 2000]

Role of the Family

Throughout high school, part of the family's role is to encourage independence, self-awareness about abilities, social skills, and community survival skills. The family can help the student set realistic goals. Graduation may be one of those goals, and it can take many forms, including delaying graduation if the student will benefit from more instruction in order to be productive in post-school activities.
Education issues during adolescence need to be continually addressed and the IEP/504/healthcare plan updated as the student's health, goals, or competencies change. There are some key points along the way that need particular attention, as listed below.

Timeline for Transition

Usually, students who stay in the system until their 22nd birthday will either exit at the end of the school term or on their birthday. Check with your local school district for their policy.

Ages 14-16

The following recommendations apply for all students, however the transition plan MUST be initiated as part of the IEP process when the student is 16. Focus on the student's goals for post-high school living.
  • Start thinking about graduation goals and become familiar with state and school district's graduation requirements and diploma options. Special Education students should learn about applying to stay in school after 18, if necessary.
  • Identify classes and credits required to complete graduation and schedule classes and curriculum accordingly.
  • Consider social issues, including recreation and sexuality.
  • Consider driver education. See Transportation - Where's My Ride.
  • Identify job interests and abilities including activities such as career exploration, job sampling, and some job training. See Employment/Daytime Activities.
  • Consider summer employment or volunteer experience.
  • Begin to identify community services that provide job training and placement.
  • Prepare a job placement file with references and skills that have been acquired.
  • Begin applying to adult service agencies like State Services for People with Disabilities, Vocational Rehabilitation, and applicable independent living services. Some agencies may have long waiting lists.
  • Ask the school team about required examinations or competency tests required for all students for graduation, if applicable.

Ages 16-18

Contact appropriate adult services programs regarding:

Ages 17-18

Depending on the extent of disability, some students may remain in school until their 22nd birthday if they are receiving special education services to accomplish their transition goals.

Ages 18-21

  • Continue to review and update the student's IEP transition plan.
  • Establish needed health benefits.
  • Develop long-range financial support plan (e.g. SSI).

Graduation Options in Utah

The lists below show the exit document options and requirements for Utah's students. Check with your IEP/school team for any changes. [Utah Secondary School Completion & Diploma Rules]

Basic High School Diploma*

  • Student must successfully complete all state and district course requirements for graduation.
  • Student must pass all subtests of the Utah Basic Skills Competency Test (UBSCT).

Alternative Completion Diploma*

  • Student must successfully complete all state and district course requirements for graduation.
  • Student must provide documentation of at least three attempts to take and pass all subtests of the Utah Basic Skills Competency Test (UBSCT)**.

Certificate of Completion

  • Student has completed his/her senior year, is exiting the school system, and has not met all state or district requirements for a diploma.
  • Student may or may not have participated in the Utah Basic Skills Competency Test (UBSCT).
*These are both considered Regular High School Diplomas.
**Note: For a small percentage of students placed in special education, the IEP/school team may determine that participation in statewide assessment is through Utah's Alternative Assessment (UAA). For these students, three attempts of the UBSCT are not required. In order to be eligible to take the UAA, the student must meet all of the requirements outlined in Utah's Special Education Graduation Guidelines (PDF Document 82 KB),

High School Graduation Decisions

Graduation issues must be addressed by the IEP team on an individual basis, preferably as the student enters high school. This discussion should include the student's participation in state-wide assessments, earning/awarding of course credits for graduation, and possible implications of earning either a diploma or certificate of completion.

Vocational Rehabilitation

Vocational Rehabilitation (also called Voc. Rehab. or VR) is a program which assists eligible people with disabilities to prepare for and obtain a job. This training may include:
  • Counseling and guidance - working closely with the client to provide support and assistance as he/she works toward reaching the job goal;
  • Medical/psychological treatment - clients may be referred for services from a doctor or therapist to help improve their disability so they can work;
  • Training and education - options include on-the-job training, self-employment, supportive employment, short-term vocational training, and college or university training;
  • Assistive technology (AT) - qualified clients may receive special equipment that will help reach his/her job goal, as well as training on how to use the equipment;
  • Job placement - may include job coaching, on-the-job training, or referral to an employment service;
  • Other services - may include assistance with transportation, tools or equipment, or readers or interpreters.

Your state vocational rehabilitation contact, listed at National Center on Secondary Education and Transition, can provide you with more details about options and services in your state.


Information & Support

For Parents and Patients

Going To College
This website is for teens with disabilities who are preparing for college. It has information about using your strengths and learning styles to be successful; knowing what to expect in college classes; and preparing (including to-do lists for high school students) and applying for college.

Center for Parent Information and Resources (DOE)
A large resource library related to children with disabilities. Parent Centers in every state provide training to parents of children with disabilities. Lists local conferences, support groups, advocacy tips, and suggestions for finding schools and other local services; Department of Education, Office of Special Education.

State Education Contacts and Information
Contact the department of education in your state, or the adult ed, arts, child care, higher ed, humanities, libraries, PTA, special ed, tech-prep, vocational rehabilitation, vocational-technical, or other education office in your state.

National Center on Secondary Education and Transition
Provides information about transition during high school and to opportunities after high school including jobs, vocational education, and college. Provides links to contacts in each state for 1) State Transition Contact, 2) Regional Resource Center Contact, 3) State Director of Special Education, 4) Part B Contact, and 5) State Director or Vocational Rehabilitation.
Provides information, discussion board, listserve, resources, student stories, and links to colleges and programs that support youth with intellectual disabilities.

Keeping It Real: How to Get the Supports You Need for the Life You Want
This curriculum supports students as the transition from high school to adulthood and provides information and tools relating to transition; self-assessment; supports; employment and careers; education and training; living arrangements, recreation and leisure; and resources; from the University of Medicine and Dentistry of New Jersey.

Transition - Education - A Guide for Health Care Providers (PDF Document 119 KB)
Tips about preparing for transition to adulthood in the school setting, from "Transition Planning for Adolescents with Special Health Care Needs and Disabilities: A Guide for Health Care Providers."

Utah Basic Skills and Competency Test
Utah Basic Skills and Competency Test information for graduation.

Utah's Transition Action Guide: for Students with Disabilities and Agencies (PDF Document 151 KB)
Provides color-coded lists of what to expect from and responsibilities of different groups (students, teachers, agencies) involved in high-school transition; developed by the Utah Employment Partnership and adapted from the Wisconsin Transition Action Guide for Post-School Planning.

Transition - Education (PDF Document 119 KB)
This handout provides tips to help youth and young adults get the services they need from schools, and suggests things to consider in transitioning to college and beginning to use adult health care services. From the Institute for Community Inclusion at Children's Hospital, Boston.

Life After High School (PDF Document 43 KB)
This handout provides brief information for planning for college or work after graduation; from the Kentucky Commission for Children with Special Health Care Needs.

Jobs: What Job Do You Do? (PDF Document 42 KB)
This handout provides brief information about jobs including considering talents, experiences, and benefits or working; from the Kentucky Commission for Children with Special Health Care Needs.

Youth/Young Adult Transition Needs Assessment (Word Document 91 KB)
A worksheet to help the youth or young adult determine strengths and needs to help prepare for transition to adulthood; from the Utah Family Voices Health Information & Support Center.


Contributing Author: Gina Pola-Money - 12/2005
Reviewing Author: Alfred Romeo, RN, PhD - 8/2008
Content Last Updated: 11/2008


Thank you to the Utah Medical Home Young Adult Advisory Committee for reviewing this section.

Page Bibliography

American Academy of Pediatrics Committee on Children With Disabilities.
The role of the pediatrician in transitioning children and adolescents with developmental disabilities and chronic illnesses from school to work or college. American Academy of Pediatrics. Committee on Children With Disabilities.
Pediatrics. 2000;106(4):854-6. PubMed abstract
A good overview of the process, the players and the physician's role.