Skip Navigation

Strengthen the Evidence for Maternal and Child Health Programs

New: MCHbest strategies database for sample ESMs

Evidence Tools
MCHbest. NPM 12: Health Care Transition

MCHbest Logo happy young man working on a tablet

Strategy. Planning for Transition + Transfer Assistance + Integration into Adult Care

Approach. Provide planning, transfer assistance, and integration into adult care activities to increase the percent of adolescents who received services to prepare for the transition from pediatric to adult health care.

Return to main MCHbest page >>

Overview. Studies demonstrate that a structured health care transition process results in positive outcomes in the triple aim domains of population health, patient experience of care, and utilization. Multicomponent interventions continue to grow in prominence and show value in improving transitions to adult health care. Research indicates that interventions using multiple elements of a transition strategy can be effective in achieving a successful transition to adult care. Elements of planning for transition include disease education/skill building and plan of care/medical summary/electronic medical information. Elements of transfer assistance include identifying an adult provider/scheduling assistance and transfer summary sent from pediatrician or shared with new adult provider. Elements of integration into adult care include welcome/orientation process and scheduling assistance/follow-up with patient after adult first visit/monitoring appointments.1-5

Evidence. Emerging. Multicomponent interventions appear to be effective in preparing youth to transition to adult health care services. Initial research showed positive results for this strategy, 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 referrals from pediatricians and transition appointment attendance; reduced time lapse between pediatric and first adult-care appointment; improved record-keeping and documentation; increased patient knowledge, self-management, and care satisfaction. 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, transfer assistance, and integration into adult care activities 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 clinics providing a structured health care transition process consisting of planning for transition, transfer assistance, and integration into adult care.
  • Number of youth served in structured health care transition programs.
  • Number of pediatric providers participating in at least one quality improvement project on transition.

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

  • Percent of clinics providing a structured health care transition process consisting of planning for transition, transfer assistance, and integration into adult care.
  • Percent of youth served in structured health care transition programs.
  • Percent of pediatric providers participating in at least one quality improvement project on transition.

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

  • Number of months between the last pediatric and first adult clinic visit.
  • Number of youth who report having access to the community-based resources necessary to make the transition to adult health care.
  • Number of youth who have successfully transitioned from pediatric to adult health care providers/practices.

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

  • Percent of youth who report having access to the community-based resources necessary to make the transition to adult health care.
  • Percent of youth who have successfully transitioned from pediatric to adult health care providers/practices.
  • Percent of youth who report a higher level of independence from parents, social participation, employment, or educational pursuit after completing a structured health care transition process.

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 Essaddam L, Kallali W, Jemel M, et al. Implementation of effective transition from pediatric to adult diabetes care: epidemiological and clinical characteristics-a pioneering experience in North Africa. Acta Diabetologica. 2018;55(11):1163‐1169. doi:10.1007/s00592-018-1196-x.

2 Jones MR, Robbins BW, Augustine M, Doyle J, Mack-Fogg J, Jones H, White, PH. Transfer from pediatric to adult endocrinology. Endocrine Practice. 2017;23(7):822–830. https://doi.org/10.4158/EP171753.OR.

3 Kosola S, Ylinen E, Finne P, Ronnholm K, Fernanda O. Implementation of a transition model to adult care may not be enough to improve results: National study of kidney transplant recipients. Clinical Transplantation. 2018;33(1):p.e13449-n/a. https://doi.org/10.1111/ctr.13449.

4 Mackie AS, Rempel G, Kovacs AH, Kaufman M, Rankin KN, Jelen S, Hons B, Yaskina M, Sananes R, Oechslin E, Dragieva D, Mustafa S, Williams E, Schuh M, Manlhiot C, Anthony S, Magill-Evans J, Nicholas D, McCrindle BW. Transition intervention for adolescents with congenital heart disease. Journal of the American College of Cardiology. 2018;71(16):1768-1777. https://doi.org/10.1016/j.jacc.2018.02.043.

5 White M, O’Connell MA, Cameron FJ. Clinic attendance and disengagement of young adults with type 1 diabetes after transition of care from paediatric to adult services (TrACeD): a randomised, open-label, controlled trial. The Lancet Child & Adolescent Health. 2017;1: 274–283.

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.