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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. Transfer Assistance + Integration into Adult Care

Approach. Provide transfer assistance and integration into adult care 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. Multicomponent interventions continue to grow in prominence and show value in improving transitions to adult health care. Elements of transfer assistance include letter of referral/coordination of referrals and transfer summary sent from pediatrician or shared with new adult provider. Elements of integration into adult care include self-care skills assessment. A coordinated care pathway with specialized pediatric care and transition to a multidisciplinary adult team accustomed to managing complex disability can be associated with better health status.1

Evidence. Emerging. 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. Greater coordination of referrals and transfer of medical summaries from pediatric to adult providers; increased collection of patient data during visits; enhanced completion of self-care skills assessments; increased submission of follow-up questionnaires to patients and families after transition. 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 transfer assistance and integration into adult care 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 youth of transition age connected to an adult health care provider.
  • Number of clinics collecting follow-up data from youth and families after the health care transition.

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

  • Percent of youth of transition age connected to an adult health care provider. 
  • Percent of youth who report a high level of satisfaction with the transfer and integration into an adult health care practice.
  • Percent of youth who received appointment scheduling assistance that included follow-up after the first adult care visit.

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 scored high on a self-care skills assessment.

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 who report receiving high quality care after transitioning to the adult health care system.

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 Paepegaey AC, Coupaye M, Jaziri A, Menesguen F, Dubern B, Polak M, Oppert JM, Tauber M, Pinto G, Poitou C. Impact of transitional care on endocrine and anthropometric parameters in Prader-Willi syndrome. Endocrine Connections. 2018;7(5):663-672.

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.