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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. Six Core Elements of HCT™

Approach. Implement the Six Core Elements of HCT™ through learning collaboratives in healthcare systems to support transition from pediatric to adult care with ongoing quality improvement

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Overview. The Six Core Elements of Health Care Transition (HCT 3.0), developed by Got Transition, provide a structured, evidence-based framework to guide adolescents and young adults from pediatric to adult healthcare.[1,2] These customizable elements include: (1) transition policy, (2) tracking and monitoring, (3) readiness assessment, (4) transition planning, (5) transfer of care, and (6) transition completion.[1] Research demonstrates that implementing the Six Core Elements in practice improves transition outcomes by helping young patients develop self-advocacy, self-care, and decision-making skills, while enhancing communication between pediatric and adult providers.[2,3,4] The framework can be adapted across various healthcare settings, including primary care, specialty practices, and hospital systems.[1] Title V programs can support implementation through Got Transition's easy-to-use toolkits and step-by-step Implementation Guides, which can be integrated into electronic health records to provide structured guidance to clinics.[2,5] Multiple quality improvement collaboratives and peer-reviewed studies have documented successful implementation of this approach, showing improved transition care processes and increased patient readiness for adult care.[3,4,5] These resources and evidence-based tools are available at https://www.gottransition.org/six-core-elements/implementation.cfm

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:

  • Learning collaborative participation and engagement data
  • Documentation of Six Core Elements Implementation by participating sites
  • Qualitative feedback from learning collaborative participants

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. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-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 practices for programs participating in a learning collaborative to implement the Six Core Elements. (Measures adoption of evidence-based framework)
  • Number of providers trained on the Six Core Elements through the learning collaborative. (Measures workforce development reach)

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

  • Percent of participating sites that have implemented all Six Core Elements with fidelity. (Measures adherence to evidence-based framework)
  • Percent of providers in participating sites who demonstrate proficiency in transition best practices. (Measures workforce capacity)

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

  • Number of participating sites that have established partnerships with adult providers to support transition. (Measures cross-setting collaboration)
  • Number of participating sites that have integrated the Six Core Elements into their EMR system. (Measures systems-level integration)
  • Number of youth in participating sites who transfer to an adult model of care with a warm handoff. (Measures linkage as defined in Six Core Elements)
  • Number of youth in participating sites who have an identified adult provider and first appointment scheduled. (Measures transition preparation)

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

  • Percent of QI initiatives in the learning collaborative that reduce gaps in transition outcomes. (Measures reach of QI initiative)
  • Percent of participating sites dedicating resources to transition-age youth proportional to their needs. (Measures strategic resource allocation)
  • Percent of youth in participating sites who complete key transition milestones on time (e.g., transfer by age 18). (Measures adherence to benchmarks)
  • Percent reduction in care gaps during transition at participating sites, compared to baseline for non-participating sites. (Measures impact on continuity)

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] 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.
[2] Cox, J., Lyman, B., Anderson, M., & Prothero, M. M. (2022). Improving Transition Care: A Transition Toolkit Implementation Project. The Journal for Nurse Practitioners, 104475.
[3] Arons, A., Tsevat, R. K., Hotez, E., Huang, H., Nott, R., Ahn, H., Mehta, N., Nguyen, L., Nguyen, V., Rebollar, A. G., Duan, S., & Ma, J. (2024). A Quality Improvement Initiative to Improve Health Care Transition Planning at Adolescent Well Visits. Academic Pediatrics, 24(6), 973–981.
[4] Osunkwo, I., Cornette, J. S., Noonan, L., Courtlandt, C., Mabus, S., White, P. H., McManus, M., Robinson, M. M., Wallander, M. L., Eckman, J. R., Saah, E., Alvarez, O. A., Goodwin, M., Jerome Clay, L., Desai, P., & Lawrence, R. H. (2024). Results of a healthcare transition learning collaborative for emerging adults with sickle cell disease: the ST3P-UP study transition quality improvement collaborative. BMJ Quality & Safety, bmjqs-2024-017725.

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.