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Transition Toolkit

Health care transition is the process of changing from a pediatric to an adult model of health care. The goal of transition is to optimize health and assist youth in reaching their full potential.

To achieve this goal requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in care.

This website includes a number of tools and resources to assist providers, families and youth in making the transition from pediatric to adult health care.

These tools and resources include tools that have been tested around the country and by clinics and families in Minnesota through the Minnesota Transition Collaborative facilitated by Family Voices of Minnesota and funded by the Children and Youth with Special Health Needs Section at the Minnesota Department of Health and the National Health Care Transition Center.

The Six Core Elements of Health Care Transition 2.0 are intended for use by pediatric, family medicine, med-peds, and internal medicine practices to assist youth and young adults as they transition to adult-centered care.

 

The Six Core Elements of Health Care Transition are aligned with the AAP/AAFP/ACP Clinical Report on Transition. Sample clinical tools and measurement resources are available for quality improvement purposes at www.GotTransition.org

Six Core Elements for Transition
Introduction to the 6 core elements of transition. The Maternal and Child Health Bureau (MCHB) national transition center, the National Alliance to Advance Adolescent Health (www.gottransition.org) created 6 core elements for developing a program to transition youth with special health needs to adult care. This document outlines the 6 core elements.
Introduction to the 6 Core Elements for […]
Adobe Acrobat document [61.1 KB]
Starting a Transition Improvement Project
Starting a Transition Improvement Project-This document is a step by step guide how to develop a transition improvement project by the experts from the National Alliance to Advance Adolescent Health, the MCHB national transition center (www.gottransition.org)
Starting a Transition Improvement Proces[…]
Microsoft Word document [148.0 KB]
Transition Youth to Adult Care
Complete set of tools for transition to adult provider (word document for individualized editing) This document contains all the tools of the 6 core elements for developing a program for youth with special health needs to transition to adult care. This word document can be edited for use.
1TransitioningYouthtoAdultCarePackage (1[…]
Microsoft Word document [6.2 MB]
Complete set of tools for transition for youth to adult approach in care (word document for individualized editing) This document contains all the tools of the 6 core elements for developing a prog
2YouthtoAdultApproachtoCareWithoutChangi[…]
Microsoft Word document [5.3 MB]
Coding and Reimbursement Tip Sheet for Transition from Pediatric to Adult Health Care
To support the delivery of recommended transition services in pediatric and adult primary and specialty care settings, Got Transition and the American Academy of Pediatrics partnered to develop this transition payment tip sheet. It begins with a summary of alternative payment methodologies followed by a listing of transition-related CPT codes and corresponding Medicare fees, effective as of 2015.
New Coding And Reimbursement Tip Sheet f[…]
Adobe Acrobat document [706.8 KB]
Integrating the Young Adult Into Adult Health Care Package
Complete set of tools to integrate young adult into adult care. (word copy for individualized editing.) This document contains all the tools of the 6 core elements for developing a program for youth with special health needs to integrate into adult care. This word document can be edited for use.
3IntegratingYoungAdultsintoAdultHealthCa[…]
Microsoft Word document [6.6 MB]
Welcome – Orientation letter to Adult Health Care
Sample welcome letter to an adult provider. This document is a sample welcome/orientation letter to an adult provider. Clinics can use it to welcome youths with special health needs and their families into adult health care.
Welcome-Orientation letter to adult heal[…]
Adobe Acrobat document [69.0 KB]
Sample Welcome Letter to Adult Specialists
Sample welcome letter to adult specialist-This document is a sample of a welcome letter to orient youth with special health needs and their families to an adult specialist.
Sample welcome letter to adult specialis[…]
.docx File [429.8 KB]

The Minnesota Transition Collaborative was started in 2012 and funded by the National Health Care Transition Center and the Children and Youth with Special Health Needs Section at the Minnesota Department of Health until 2015.

The Collaborative included four clinics:  Hennepin County Medical Center, Essentia Clinic – Duluth, HealthPartners Como and White Bear Lake and CentraCare Women and Children’s Clinic.  These clinics with the assistance of families and youth from their clinics developed a transition program within their organization using the 6 Core Elements of the Maternal and Child Health Bureau national transition center.

The following information provides samples of the tools developed and used by the various clinic transition teams during the Collaborative.

Samples of Transition Policies

The following documents are samples of transition policies developed by the CentraCare Women and Children’s Clinic and Essentia Clinic – Duluth using the 6 core elements.

CentraCare Women’s and Children’s Clinic Transition Policy
CentraCare Transition Policy.doc
Microsoft Word document [57.0 KB]
Essentia Clinic in Duluth transition policy
Duluth transition policy.pdf
Adobe Acrobat document [198.7 KB]

Samples of Transition Readiness Assessments

The following documents are samples of Transition Readiness Assessments from the 6 core elements.  However, these Readiness Assessments were edited by the clinic transition teams including family and youth partners for the clinics individual use.  

CentraCare Women’s and Children’s Clinic Transition Readiness Assessment
CentraCare Transition Policy.doc
Microsoft Word document [57.0 KB]
Essentia Clinic – Duluth – Transition Readiness Assessment for Families
Duluth readiness assessment for famlies.[…]
Adobe Acrobat document [93.8 KB]
Essentia Clinic – Duluth – Transition Readiness Assessment for Youth
Duluth readiness assessment for youth).p[…]
Adobe Acrobat document [90.5 KB]
Hennepin County Medical Center Transition Readiness Assessment – Epic Version
This document of an edited version of the Transition Readiness Assessment for use in the EPIC electronic health record.
Hennepin County transition Readniness Li[…]
Microsoft Word document [96.5 KB]
Northern Lights School Transition Readiness Assessment
Northern Lights School Transition Readiness Assessment-This document is a Transition Readiness Assessment taken from the Essentia Readiness Assessment for use with youth with special health to support their education transition program
Northern Lights School Readiness Assessm[…]
Microsoft Word document [24.3 KB]
Hennepin County Medical Center Transition Brochure
Hennepin County Medical Center Transition Program Brochure-This is a sample of a brochure developed for families and youth planning transition in health care at Hennepin County Medical Center.
Hennepin County sample brochure Transiti[…]
Adobe Acrobat document [254.1 KB]
Hennepin County Transition Packet – list of contents of packets for families
Hennepin Transition Packet-This document is a list of the contents of a transition packet developed for youth with special health needs and their families planning transition in health care.
Hennepin County transition Readniness Li[…]
Microsoft Word document [96.5 KB]

Other Resources Identified by Clinics, Families and Youth

Also see resources under Family/Youth and Caregiver for more family and youth freindly information.

Ages and Skills in Transition
This document is a transition timeline for use with youth with special health needs and their families. It charts transition skills to be presented according to developmental age. This information if credited to Carolina Health and Transition (CHAT) The North Carolina Division of Public Health, Women and Children’s Health Section Children & Youth Branch. (2009)
Ages and skills in transition.pdf
Adobe Acrobat document [77.6 KB]
Differences in Care
This is good information to share with families and youth. It compares pediatric and adult health care and assists families and you to understand why they need to prepare for transition to adult care. This document was developed y UIC-Division of Specialized Care for Children and the Illinois Chapter of the American Academy of Pediatrics.
Differences in Care..docx
.docx File [592.7 KB]
Preparing for College:
This document discusses how to prepare for college when a youth has a special health need. Developed by www.gottransiton.org.
Preparing for College..pdf
.pdf File [1.1 MB]
Finding and Using Adult Health Care
This hand-out provides guidance in finding and selecting an adult doctor.
finding_adult_hc.pdf
Adobe Acrobat document [92.1 KB]
The Differences between Pediatric and Adult Care
This is a great hand-out about the differences in receiving care in Pediatrics and care from an adult doctor. It provides ways to prepare for transferring care from Pediatrics to Adult care.
Differences in care from Pediatric to Ad[…]
Adobe Acrobat document [548.2 KB]
Transition Readiness Tool for Youth
3.3 ReadinessYouthTool.pdf
Adobe Acrobat document [414.8 KB]
Health_Passport for youth-English.pdf
Adobe Acrobat document [548.0 KB]
My Health Passport English and Spanish
Good tool for youth with health needs and disabilities. This tool provides an opportunity for the youth to let health providers know about their needs.
Health passport for youth-Spanish.pdf
Adobe Acrobat document [563.5 KB]
ARC Guide to Guardianship and Conservatorship
This is a good guide to help families think about guardianship and conservatorship for their youth with developmental disabilities.
ArcGuideGuardianshipConservatorshipMay20[…]
Adobe Acrobat document [131.7 KB]
Tips for Communicating with Doctors
This article provides a good list of things to do to prepare for a doctor’s appointment.
comm_w_doctor.pdf
Adobe Acrobat document [114.5 KB]