MCH Best. NPM 12: Health Care Transition
Strategy. Six Core Elements Adaptation with Quality Improvement (QI)
Approach. Incorporate the Six Core Elements™ in a learning collaborative or medical center/hospital system with built-in QI activities.
Overview. Current research has shown that adaptation of the Six Core Elements of Health Care Transition1 in practice (including written plan and other services) may improve transition.2 The Six Core Elements of Health Care Transition is a structured process that encompasses transition planning, transfer of care, and integration into adult care that can be customized and applied in a variety of different pediatric and adult health care settings and programs.3
Evidence. Moderate Evidence. Having a structured health care transition process in place for youth with special health care needs is associated with significant positive outcomes related to population health, consumer experience, and service utilization. Access the peer-reviewed evidence through Outcome Evidence for Structured Pediatric to Adult Health Care Transition Interventions: A Systematic Review and Outcomes of pediatric to adult health care transition interventions: An updated systematic review (Got Transition®/Center for Health Care Transition Improvement). The American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians call for the use of the Six Core Elements in their 2018 Clinical Report. (Access the Clinical Report, Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home at Got Transition). (Read more about understanding evidence ratings).
Target Audience. Health care practices/clinics/systems, care coordination programs, managed care organizations, public health programs.
Outcome. Can be measured in several ways -- self-care knowledge/skills, adherence to care, disease-specific measures, clinician experience with transition process, time between last pediatric and initial adult visit, preventive/ambulatory care visits in adult settings, emergency room visits, hospital use, and costs of care.
- Process: Can be measured using Got Transition’s tools for assessing level of implementation of the Six Core Elements in pediatric and adult settings: 1) Current Assessment of Health Care Transition Activities and 2) Health Care Transition Process Measurement Tool.
- Consumer experience: Can be measured using Got Transition’s Health Care Transition Feedback Survey (for youth/parents or caregivers/young adults).
- 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. There are currently 13 ESMs across all states/jurisdictions that use this strategy directly or intervention components that align with this strategy. Access descriptions of these ESMs through the MCH Digital Library. You can use these ESMs to see how other Title V agencies are addressing the NPM.
Sample ESMs. Using the approach “Incorporate the Six Core Elements of Health Care TransitionTM in a learning collaborative or medical center/hospital system with built-in QI activities,” 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).
Note and Reference:
1 The Six Core Elements include: (1) transition policy, (2) transition tracking and monitoring, (3) transition readiness, (4) transition planning, (5) transfer of care, and (6) transfer completion.
2 White PH, Cooley WC, Transitions Clinical Report Authoring Group, American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics. 2018;142(5):e20182587
3 Got Transition is now offering the updated Six Core Elements of Health Care Transition™ 3.0, which define the basic components of HCT support. The Six Core Elements 3.0 are intended for use by pediatric, family medicine, med-peds, and internal medicine practices.To help practices transform their HCT processes, Got Transition has also developed new practical step-by-step Implementation Guides dedicated to each core element. Got Transition offers background information on how to use the Implementation Guides, as well as a Quality Improvement Primer for those unfamiliar with the QI process. Guides and information are available at www.GotTransition.org/Implementation.