MCHbest. NPM 12: Health Care Transition
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.
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):
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 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.