MCHbest. NPM 12: Health Care Transition
Strategy. Planning for Transition + Transfer Assistance
Approach. Provide planning activities and transfer assistance to increase the percent of adolescents who received services to prepare for the transition from pediatric to adult health care.
Overview. Research indicates that interventions that combine planning for transition with transfer assistance will increase the likelihood that adolescents will successfully transition from pediatric to adult health care services. Examples of positive studies that used this strategy took into consideration the patients’ perspective and relied on multidisciplinary teams to help ensure a coordinated, comprehensive, and supportive transition process. Planning includes tracking/monitoring, disease education/skill building and a plan of care/medical summary/electronic medical information. Transfer assistance includes identifying an adult provider, a letter of referral/coordinating of referrals, providing scheduling assistance, fostering communication between pediatrician and adult providers, and arranging joint meetings. A transition clinic that coordinates planning and transfer assistance can be instrumental in improving health outcomes and reducing the number of hospital stays among transitioning adolescents with special health care needs.1
Evidence. Mixed. Initial research showed positive results for this strategy, but further research is needed to confirm effects. Some studies that combined planning for transition + transfer assistance showed mixed evidence and/or lacked sufficient outcome data. 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 use of multidisciplinary transition teams; decreased transition period between pediatric and adult care; reduced cost of care; improved knowledge of health needs by patients; and increased quality of life, social participation, and independence. 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 activities and transfer assistance 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):
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).
1 Bennett, A. L., Moore, D., Bampton, P. A., Bryant, R. V., & Andrews, J. M. (2016). Outcomes and patients’ perspectives of transition from paediatric to adult care in inflammatory bowel disease. World Journal of Gastroenterology. doi: 10.3748/wjg.v22.i8.2611.