Transitions of Care

A Successful Approach to Managing Pediatric to Adult Transitions of Care

Transitioning from a pediatric to an adult provider can be a challenge for all members of the care team. Transitions toolkits have been developed for Type 1 Diabetes, Growth Hormone Deficiency, and Turner Syndrome to help ease this transition.

Type 1 Diabetes

• Provider Assessment of Patient Skill Set : A checklist to help the pediatric care team begin a conversation with the patient about what they need to do to successfully manage their diabetes without parental supervision.
• Patient Self-assessment of Worries, Concerns, and Burdens : An assessment of relevant psycho-social, familial, and cognitive factors that the adult care team should be aware of when caring for their new patient.
• Recommended Approach to Planning for Pediatric Practices: Pediatric practices with a guide for how to begin the transition process for patients with type 1 diabetes.
• Clinical Summary : A template for the pediatric care provider to summarize the patient’s medical record, which is then transferred to the adult care provider.
• Recommended Approach to Receiving a New Patient: Receiving suggestions for the adult provider and includes information on how to begin the final phase of the transition.
• "Welcome to the Practice" Guide: A tool for developing practice resources to be given to new patients with information on transportation, after-hours contact information, lab testing/results, etc.
• Visitor Information Form : A form for use by the emerging adult when first seeing their new provider to let them know who can be informed of personal health information or be allowed in the room during examination.

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Growth Hormone Deficiency

• Assessment of Patient Skills : A checklist to help the pediatric care team begin a conversation with the patient about what they need to do to successfully manage their growth hormone deficiency without parental supervision.
• Patient Self-assessment of Worries, Concerns, and Burdens : An assessment of relevant psycho-social, familial, and cognitive factors that the adult care team should be aware of when caring for their new patient.
• Clinical Summary : A template for the pediatric care provider to summarize the patient’s medical record, which is then transferred to the adult care provider.
• Recommended Approach to Receiving a New Patient: A resource for the adult provider and includes information on how to begin the final phase of the transition.
• Dosing Guide : An overview of dosing strategies for patients with growth hormone deficiency.

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Turner Syndrome

• Provider Assessment of Patient Skill Set: This tool helps pediatricians to assess a young adult’s knowledge and skills regarding Turner Syndrome and its management in preparation for his/her transition to adult care providers.
• Transition Readiness Assessment : An assessment tool for adult care providers to identify gaps in self-care knowledge and skills, and to discuss any of these issues with their patients to ensure optimal management of their medical condition.
• Clinical Summary & Transfer Record : A form to ensure that all essential clinical information related to the patient’s condition is included in his/her medical record upon transfer to adult practice. It must be completed by the referring provider and patient.
• Dosing Standards for Estrogen: A guide for both pediatric and adult providers with an overview of dosing strategies for patients with Turner Syndrome.
• Recommended Approach for Transitioning into Adult Practice: A resource for adult providers who plan to receive emerging adults with Turner Syndrome.
• Recommended Approach for Planning for Pediatric Practices: A resource for pediatricians who are preparing to transition their young adult patients with Turner Syndrome to an adult provider.
• Adult Care Recommendations for Screening & Assessment : A chart to inform patients about which provider should be responsible for conducting various screenings and other assessments needed in adulthood.

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