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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. 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

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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 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:

  • Data pertaining to adolescent preparedness for transition
  • Qualitative feedback from adolescents and families
  • Data from interagency collaboration and agreements

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

  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • 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 adolescents who receive transition planning services, including disease education and skill-building. (Measures reach of preparatory services for transition planning)
  • Number of providers trained on delivering transition planning, transfer assistance, and care coordination. (Measures breadth of workforce capacity building among healthcare providers)

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

  • Percent of transition program services aligned with evidence-based models and best practices. (Measures program fidelity to proven interventions and best-practices)
  • Percent of pediatric and adult providers who participate in joint transition planning meetings. (Measures level of cross-cutting collaboration among healthcare providers)

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

  • Number of transition coordinators who participate in a learning collaborative for community of practice. (Measures level of peer learning and support among transition coordinators)
  • Number of policies or protocols developed to support transition, e.g., information transfer, referral pathways. (Measures development of policy infrastructure around healthcare transition support)
  • Number of adolescents who attend a scheduled appointment with an adult provider within 6 months of transition. (Measures successful linkage to adult care)
  • Number of adolescents referred to and enrolled in adult services. (Measures reach and impact)

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

  • Percent of transition coordinators who participate in a learning collaborative for community of practice. (Measures level of peer learning and support among transition coordinators)
  • Percent of policies or protocols developed to support transition, e.g., information transfer, referral pathways. (Measures development of policy infrastructure around healthcare transition support)
  • Percent of adolescents with multiple comorbidities who achieve a smooth transfer to adult care. (Measures outcomes for population of focus)
  • Percent of adolescents who maintain continuity of health insurance coverage during transition. (Measures systems-level outcomes related to maintenance of health insurance among adolescents during the transition period)

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 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).

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.