1. Have a policy or a planned approach for transitioning patients.

  • Have a written plan or approach.
  • Articulate that plan or approach to the patient and family (“we care about you and want to be sure you are prepared as you mature and go into your adult life”).

2. Have a youth registry to identify who is ready to start the transition process as well as to track progress and outcomes.

3. Transition Preparation/Readiness Assessment

  • Identify a skill set for independent self-care (suggested language for patients: “we want to be sure you are prepared to transition/we want to help prepare you for transition”).

4. Transition Planning

  • Develop an action plan with shared goals.
  • Help parents with transition roles; assignments within the action plan.
  • Work with patient to develop and review portable medical summary and emergency care plan.

5. Transition and Transfer of Care

  • Exchange information with the adult care provider.
  • Send transition package of necessary medical records.

6. Transition Completion

  • Continue to provide medical advice and support to the young adult patient until the transition is complete.
  • Put measures in place in the pediatric practice to “close the loop” and ensure that transitioning patient is established in adult care.

Adapted from “Got Transition” Six Core Elements of Health Care Transition — www.gottransition.org