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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 + Transfer Assistance + Integration into Adult Care + Care Coordination

Approach. Provide planning activities, transfer assistance, integration into adult care, and care coordination 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. The latest clinical guidance calls on researchers to incorporate multiple components of HCT into their study designs. Studies demonstrate that a structured health care transition process results in positive outcomes in population health, patient experience of care, and utilization. Interventions that combine planning for transition + transfer assistance + integration into adult care + care coordination further increases the likelihood that adolescents will successfully transition from pediatric to adult health care. Examples of studies that showed positive outcomes using this comprehensive approach helped youth of transition age navigate through available services (mental, physical, and financial); assessed the usefulness of transition policy, clinical decision support, and transfer/registry tool templates; and set up joint consultation sessions with both pediatric and adult care providers present. The transition care was coordinated, and patients’ perceptions of their health care transition process were recorded.1-7

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 combined 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. Completed transition plan of care; improved disease education and skill building services; designated care coordinator; identified adult provider and assistance with appointment scheduling; welcome/orientation process in place; follow-up with patient and appointment monitoring. 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, transfer assistance, integration into adult care, and care coordination 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, integration into adult care, and care coordination.
  • Number of youth with an identified provider who assumed responsibility for current health care, transfer assistance, integration into adult care, care coordination, and future health care planning.

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

  • Percent of families who report receiving information/education on the structured health care transition process.
  • Percent of youth who report being satisfied with the comprehensive, coordinated approach to health care transition.
  • Percent of youth served in structured health care transition programs.

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

  • Number of months between the last pediatric and first adult clinic visit.
  • Number of joint meetings arranged between pediatric and adult health care providers.
  • Number of patient transfer summaries sent from pediatric to adult care providers.

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

  • Percent of youth who have successfully transferred from pediatric to adult health care providers/practices.
  • Percent of youth reporting an increase in knowledge and self-efficacy due to the structured health care transition process.         
  • Percent of youth who report an increase in life satisfaction/decrease in stress/enhanced sense of well-being after transitioning from pediatric 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.


1 Agarwal, S., Raymond, J. K., Schutta, M. H., Cardillo, S., Miller, V. A., & Long, J. A. (2017). An adult health care-based pediatric to adult transition program for emerging adults with type 1 diabetes. The Diabetes Educator. doi:10.1177/ 0145721716677098.

2 Colver A, McConachie H. Le Couteur A, et al. A longitudinal, observational study of the features of transitional healthcare associated with better outcomes for young people with long-term conditions.  BMC Med. 2018; 16(1):111. Published 2018 Jul 23. doi:10.1186/s12916-018-1102-y.

3 Razon AN, et al. A multidisciplinary transition consult service: patient referral characteristics. Journal of Pediatric Nursing 2019;47: 136-141.

4 Sattoe, J.N.T., Peeters, M.A.C., Haitsma, J., van Staa, A., Wolters, V.M., Escher, J.C. Value of an outpatient transition clinic for young people with inflammatory bowel disease: a mixed- methods evaluation. BMJ Open 2020;10:e033535. doi:10.1136/bmjopen-2019-033535.

5 Schultz, L., Radkie, M., Menzel, S., Dabritz, J. (2019) Long-term implications of structured transition of adolescents with inflammatory bowel disease into adult health care: a retrospective study BMC Gastroenterology 19:128

6 Szalda D, et al. Developing a hospital-wide transition program for young adults with medical complexity. Journal of Adolescent Health 2019;65: 476-482.

7 Van Pelt, P.A., Dolhain, R., Kruize, A.A., Ammerlaan, J.J.W., Hazes, J.W., Bijlsma, J.W.J., Wulffraat, N.M. (2018). Disease activity and dropout in young persons with juvenile idiopathic arthritis in transition of care: a longitudinal observational study. Clinical and Experimental Rheumatology, 36(1), 163-168.

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.