Transition to Adult Care — Outpatient Specialty Care and Primary Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

For Institutions or Divisions Interested in Developing a Transition Program

Preparing for Transition 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
- Transition Readiness Assessment Questionnaire
  - Note: If interested in EPIC tools for transition support including the TRAQ, contact IS support
- Consider Social Work Consult
  - For example: Health Insurance, Intellectual Disability,
    Medical Decision Making 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.

Patient with Suspected or Diagnosed Intellectual Disability, Developmental Disability (Delay) or Autism

Creating a Transfer Plan
- For providers: Recommendations for content to include in final clinic
  note or letter
  - Create “Health Summary for Transition of Care” letter
- For patients: Steps for finding an adult provider and insurance
- Coordinate appointments with new providers

Implementing a Transfer Plan
- Epic communications with new provider
  - Radiology transfer
  - Care Everywhere
- 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: October 2022
Authors: D. Szalda, MD; A. Greenberg, NP; N. Stollon, MSW; S. Quinn, MD; S. Trachtenberg, MSW LSW

Evidence

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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

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Outpatient Specialty Care and Primary Care Clinical Pathwayfor Children Transitioning to Adult Care

Evidence

CHOP Program

Educational Media

Related Links

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