MCHbest. NPM 12: Health Care Transition
Strategy. Planning for Transition + Transfer Assistance + Care Coordination
Approach. Provide planning, transfer assistance, and care coordination to prepare adolescents for the transition from pediatric to adult health care services.
Overview. A structured health care transition process results in positive outcomes in population health, patient experience of care, and utilization. Interventions that combine planning with transfer assistance and care coordination seem to increase the likelihood that youth will successfully transition from pediatric to adult health care services. Examples of studies that showed positive outcomes using this three-pronged approach combined the following: 1) disease education/skill-building for youth and families during the planning phase; 2) transfer assistance that included identifying an adult provider; assisting with appointment scheduling; and fostering communication between pediatric and adult providers/joint pediatric and adult meetings; and 3) care coordination administered by a designated transition coordinator who acted as a system navigator.1-3
Evidence. Moderate/Emerging. Multicomponent interventions with activities related to planning for transition, transfer assistance, and care coordination appear to be effective in preparing youth to transition to adult health care services. Programs based on this strategy are likely to work. 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. Measurable improvements in chronic disease outcomes; reduced cost of care; increased communication among youth, families, and transition teams; and greater satisfaction reported by youth transitioning from pediatric to adult care. 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 care coordination services to prepare adolescents for the transition from pediatric to adult health care services,” 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 Farrell K, Fernandez R, Salamonson Y, Griffiths R, Holmes-Walker DJ. Health outcomes for youth with type 1 diabetes at 18 months and 30 months post transition from pediatric to adult care. Diabetes Research and Clinical Practice. 2018;139:163-169. doi:10.1016/j.diabres.2018.03.013.
2 Lemke M, Kappel R, McCarter R, D’Angelo L, Tuchman L. Perceptions of health care transition care coordination in patients with chronic illness. Pediatrics. 2018;141(5):e20173168.
3 Elizabeth A. Pyatak, Paola A. Sequeira, Cheryl L.P. Vigen, Marc J. Weigensberg, Jamie R. Wood, Lucy Montoya, Valerie Ruelas, Anne L. Peters. Clinical and psychosocial outcomes of a structured transition program among young adults with type 1 diabetes. Journal of Adolescent Health. 2017; 60(2).