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Strengthen the Evidence for Maternal and Child Health Programs

New: MCHbest strategies database for sample ESMs

Evidence Tools
MCHbest. NPM 12: Health Care Transition

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Strategy. Planning for Transition

Approach. Provide planning services to increase the percent of adolescents who received services to prepare for the transition from pediatric to adult health care.

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Overview. Studies demonstrate the importance of planning for the transition to adult health care. Research indicates that planning for transition within pediatric practices is an important element in ensuring successful continuity of care. Examples of planning activities include transition readiness/self-care skills assessment, disease education/skill building, plan of care with medical summary/electronic medical information, and patient/family feedback on transition process.1 2 3

Evidence. Emerging. Initial research showed positive results for planning for transition, but further research is needed to confirm effects. This strategy has been tested more than once and results trend positive overall. Access the peer-reviewed evidence through the references below and the MCH Digital Library. (Read more about understanding evidence ratings).

Target Audience. Youth with special health care needs.

Outcome. Increased knowledge of disease and medication adherence; decreased self-reported pain and anxiety; increased quality of life, self-advocacy, and decision-making ability among adolescents and young adults. For detailed outcomes related to each study supporting this strategy, click on the peer-reviewed evidence link above and read the “Intervention Results” for each study.

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM. You may also want to look at evidence that supports educational programs in other NPM topic areas that can be translated to this specific topic area.

Sample ESMs. Using the approach “Provide planning services to increase the percent of adolescents who received services to prepare for the transition from pediatric to adult health care,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies):

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of providers educated in health care transition best practices, including planning for transition, transfer assistance, and care coordination.
  • Number of youth who have been assigned a nurse or other health provider to serve as a transition care coordinator.
  • Number of youth with health care providers who have assumed responsibility for their current health care, transfer assistance, care coordination, and future health care planning.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percent of providers who address transition to adult health care in their practice.
  • Percent of youth and families that participate in transition planning activities.
  • Percent of clinics that collect patient/family feedback on the transition process.

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of youth who have transition plans in place by age 14.
  • Number of youth who report an increase in knowledge and self-efficacy to transition to adult health care.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percent of youth who have transition plans in place by age 14.
  • Percent of youth who report an increase in knowledge and self-efficacy to transition to adult health care.

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4).

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


References:

1 Flocco SF, Dellafiore F, Caruso R, et al. Improving health perception through a transition care model for adolescents with congenital heart disease. Journal of Cardiovascular Medicine (Hagerstown). 2019;20(4):253-260. doi:10.2459/JCM.0000000000000770.

2 Huang JS, et al. Harnessing the electronic health record to distribute transition services to adolescents with inflammatory bowel disease. Journal of Pediatric Gastroenterology and Nutrition. 2020;70:200-204.

3 Le Marne FA, et al. Implementing a new adolescent epilepsy service: improving patient experience and readiness for transition. Journal of Paediatrics and Child Health 2019;55: 819-825.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.