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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Transition.

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Strategy. Transition Care Coordination Services

Approach. Use care coordinators at clinics to help with appointments, scheduling, education, and other health care transition services

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Overview. Transition Care Coordination is a crucial strategy to enhance successful transitions for youth from pediatric to adult healthcare, particularly for those with medical complexity or chronic conditions.[1,2,3,4,5,6] It involves early and structured planning, ideally beginning around age 12-14, tailored to individual youth and family contexts.[1,3 ,5,6] Key to this approach is a multidisciplinary team including nurses, social workers, and physicians, often led by a designated coordinator or case manager, who provide instrumental and psychological support, advocacy, and guidance through the bureaucratic and emotional aspects of transition.[1,3,6,7] A centralized information transfer through detailed transition reports or "passports" ensures continuity of care between pediatric and adult providers, reducing gaps and enhancing patient and family preparedness.[3,5, 6,7] Furthermore, coordination efforts empower youth with self-management and self-advocacy skills, while advocating for adaptable adult healthcare services, improved access to mental health support, and expanded community resources to meet diverse needs,[1,2,3,6,7] Successful programs for youth with conditions like sickle cell disease demonstrate that community health worker support and mobile health programs can significantly enhance quality of life during transition.[8]

Evidence. Moderate Evidence. Strategies with this rating are likely to work...

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Care Coordinator activity logs
  • Family feedback and satisfaction data
  • Data on appointment wait times and overall satisfaction

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • Timeliness of Care. This strategy promotes delivery of healthcare services in a timely manner to optimize benefits and prevent complications.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Case Management (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Individual/Family-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy or aligned components.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort (“What/how much did we do?”)

  • Number of clinics with designated care coordinators to support health care transition. (Measures adoption of the transition strategy across settings)
  • Number of care coordination encounters provided to transition-age youth, disaggregated by service type. (Measures the volume and range of transition supports)

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

  • Percent of transition care coordination services aligned with Got Transition's Six Core Elements. (Measures adherence to evidence-based practices)
  • Percent of youth and families engaged as partners in designing the care coordination program. (Measures authentic community engagement in program development)

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

  • Number of adult providers educated by care coordinators on receiving and caring for transitioning youth. (Measures efforts to build system capacity for transition)
  • Number of transition improvement initiatives jointly implemented by pediatric and adult clinics. (Measures collaborative quality improvement across settings)
  • Number of youth with a successful first appointment with an adult provider after transition care coordination. (Measures linkage to adult care)
  • Number of youth who receive care coordination and maintain continuity of coverage during transition years. (Measures prevention of insurance gaps)

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

  • Percent of transition-age youth in the service population receiving care coordination, stratified by demographic features. (Measures reach)
  • Percent of care coordinators serving transition-age youth who demonstrate proficiency in key transition competencies. (Measures workforce skills)
  • Percent reduction in missed appointments among youth working with a transition care coordinator. (Measures impact on retention in care)
  • Percent of transition-age youth with multiple chronic conditions who achieve transition plan goals. (Measures successful transition in complex populations)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

[1] Li, L., Carter, N., Gorter, J. W., Till, L., White, M., & Strachan, P. H. (2024). A Socioecological Approach to Support the Transition to Adult Care for Youth With Medical Complexity: Family Perspectives and Recommendations. Health Expectations, 28(1).
[2] Jenkins, A. M., Burns, D., Horick, R., Spicer, B., Vaughn, L. M., & Woodward, J. (2021). Adolescents and Young Adults With Spina Bifida Transitioning to Adulthood: A Comprehensive Community-Based Needs Assessment. Academic Pediatrics, 21(5), 858–867.
[3] Cassidy, M., Doucet, S., Luke, A., & MacNeill, L. (2025). Improving the Transition from Pediatric to Adult Healthcare: Recommendations from Young Adults with Lived Experience. Canadian Journal of Family and Youth / Le Journal Canadien de Famille et de La Jeunesse, 17(2), 49–73.
[4] Champion, J., Crawford, M., & Jaaniste, T. (2023). Predicting the Need for Transition from Pediatric to Adult Pain Services: A Retrospective, Longitudinal Study Using the Electronic Persistent Pain Outcome Collaboration (ePPOC) Databases. Children, 10(2), 357.
[5] Nabbout, R., Agathe Molimard, Scorrano, G., Aubart, M., Breuillard, D., Delaune, M., Barcia, G., Chemaly, N., Marie‐Anne Barthez, & Desguerre, I. (2024). Transition from pediatric to adult care system in patients with complex epilepsies: Necker model for transition evaluated on 70 consecutive patients. Epilepsia.
[6] Bert, F., Camussi, E., Gili, R., Corsi, D., Rossello, P., Scarmozzino, A., & Siliquini, R. (2020). Transitional care: A new model of care from young age to adulthood. Health Policy.
[7] Schraeder, K., Dimitropoulos, G., Allemang, B., McBrien, K., & Samuel, S. (2020). Strategies for improving primary care for adolescents and young adults transitioning from pediatric services: perspectives of Canadian primary health care professionals. Family Practice.
[8] Jan, S., Steinway, C., Belton, T., Shults, J., Bennett, L., Griffis, H., Banu Aygun, Abena Appiah-Kubi, Nataly Apollonsky, Boruchov, D., Niss, O., Schwartz, L. A., Crosby, L. E., Barakat, L., Biree Andemariam, Rubin, D., & Smith-Whitley, K. (2024). Community Health Worker and Mobile Health Programs to Help Young Adults with Sickle Cell Disease Transition to Using Adult Healthcare Services – the Comets Study; Results from Patient-Reported Outcomes at 6 Months. Blood, 144(Supplement 1), 1066–1066.

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.