Transition to Adult Care Clinical Pathway
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Discuss Transfer of Care with Patient/Family

  • Review Division Policy if applicable
    • Every effort should be made for patients to be transitioned to adult care by age 21
    • (Review Hospital Admission Policy)
  • Consider using .transitionreview smartphrase in overview
    • Add “Counseling for Transition” to Problem List
  • Begin to see patient alone for part of visit to facilitate
    healthcare independence

Assessing Transition Readiness

  • Complete or Review Readiness Assessment (TRAQ)
  • Consider Social Work Consult
    • For example: Health Insurance, Intellectual Disability, Guardianship/Power of Attorney Concerns and Mental Health Diagnoses
    • Process for Healthcare Independence
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Consider Multidisciplinary Intervention Navigation Team (MINT) Consult

Note: MINT consult can be placed for patients who are ≥ 18 years with two or more subspecialists and/or with an intellectual disability.

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Creating a Transfer Plan

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Implementing a Transfer Plan

  • Provide patient and new providers with a copy of the transition summary
  • Update problem list with new provider information, using smartphrase: .transitionreview
  • Confirm transfer with all providers and patients.

Posted: December 2017
Authors: D. Szalda, MD; A. Greenberg, NP; N. Stollon, MSW; S. Quinn, MD; S. Trachtenberg, MSW LSW; K. Wu BA; A. Tuttle, LCSW; Z. Gajary, MD