Outpatient Specialty Care and Primary Care Clinical Pathway for Children Transitioning 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
- 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) 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
- Steps for Finding an Adult Provider and Insurance
- Primary Care and Subspecialty Homes:
- Create “Health Summary for Transition of Care” letter
- Recommendations for Content to Include in Final Clinic Note or Letter
- Coordinate appointments with new providers
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
Revised: May 2020
Authors: D. Szalda, MD; A. Greenberg, NP; N. Stollon, MSW; S. Quinn, MD; S. Trachtenberg, MSW LSW
Evidence
- Transitions of Care Consensus Policy Statement
- Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home
- Transitioning Youth to An Adult Health Care Provider
- Sample Transfer of Care Checklist
- Transitioning to Adult Care: Supporting Youth With Special Health Care Needs
- Transition to Adulthood Program
Media