Outpatient Specialty Care and Primary Care Clinical Pathway for Children Transitioning to Adult Care

Related Order Set
  • Consult to Adult Care

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) – View Policy
  • Add “Counseling for Transition” to Problem List
  • Review Patient Education as needed
  • Begin to see patient alone for part of visit to facilitate
    healthcare independence

Assessing Transition Readiness

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

Consider Adult Care and Transition Team (ACTT) Consult

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

Creating a Transfer Plan

Implementing a Transfer Plan

  • Provide patient and new providers with a copy of the transition summary
  • Update problem list with new provider information
  • Confirm transfer with all providers and patients
Posted: December 2017
Revised: May 2020
Authors: D. Szalda, MD; A. Greenberg, NP; N. Stollon, MSW; S. Quinn, MD; S. Trachtenberg, MSW LSW