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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

Approach. Provide planning activities and transfer assistance to increase the percent of adolescents who received services to prepare for the transition from pediatric to adult health care

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Overview. Research indicates that interventions that combine planning for transition with transfer assistance will increase the likelihood that adolescents will successfully transition from pediatric to adult health care services. Planning includes tracking/monitoring, disease education/skill building and a plan of care/medical summary/electronic medical information. Transfer assistance includes identifying an adult provider, a letter of referral/coordinating of referrals, providing scheduling assistance, fostering communication between pediatrician and adult providers, and arranging joint meetings. A transition clinic that coordinates planning and transfer assistance can be instrumental in improving health outcomes and reducing the number of hospital stays among transitioning adolescents with special health care needs.[1]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential 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:

  • Qualitative feedback from adolescents and families
  • Partnership activity logs
  • Staff activity reports and professional development data related to transition

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.
  • Timeliness of Care. This strategy promotes delivery of healthcare services in a timely manner to optimize benefits and prevent complications.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.

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 adolescents, with and without special health care needs (SHCN), who receive transition planning services, including tracking/monitoring, disease education/skill-building, and development of a plan of care/medical summary/electronic medical information. (Measures the reach and scope of transition planning interventions)
  • Number of transition clinics established to coordinate comprehensive transition planning and transfer assistance services for adolescents with and without SHCN. (Measures the availability and usability of specialized transition support resources)

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

  • Percent of transition planning and transfer assistance services that adhere to national guidelines, best practices, and evidence-based approaches for supporting successful transitions from pediatric to adult care. (Measures the quality and standards of transition interventions)
  • Percent of transition clinics that provide usable services to meet the different needs of adolescents and their families. (Evaluates the patient-centeredness of transition support structures)

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

  • Number of cross-sector partnerships and collaborations formed among Title V programs, health care systems, schools, social service agencies, and community organizations to provide comprehensive transition planning and transfer assistance services. (Measures the level of multi-community partner engagement and care integration)
  • Number of quality improvement initiatives, research studies, and data-sharing agreements implemented to evaluate and enhance the effectiveness and efficiency of transition interventions for different adolescent populations. (Measures the use of evidence-based practices and continuous learning to optimize transition outcomes)
  • Number of adolescents from communities who receive transition planning and transfer assistance services that address their unique needs and challenges. (Measures the impact of transition interventions on advancing health and meeting targeted needs)
  • Number of successful transition models, tools, and resources disseminated and replicated across states, health systems, and communities to promote widespread adoption of evidence-based transition practices. (Measures the potential for scaling and sustaining effective transition interventions)

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

  • Percent of transition planning and transfer assistance services that are tailored to address the specific needs, preferences, and backgrounds of adolescents from different communities and populations. (Measures the customization and responsiveness of transition interventions)
  • Percent of transition planning and transfer assistance interventions that are co-designed, implemented, and evaluated in partnership with adolescents, families, and community community partners to ensure relevance, acceptability, and shared decision-making. (Measures the level of authentic engagement and leadership of affected populations in shaping transition services)
  • Percent of adolescents who report increased resilience, self-determination, and social-emotional well-being as a result of the support, skills, and resources provided through transition planning and transfer assistance. (Measures the impact of transition interventions on promoting positive youth development and quality of life)
  • Percent of total health care expenditures for adolescents that are invested in preventive, proactive, and coordinated transition services, as opposed to reactive, fragmented, and costly crisis care. (Measures the long-term, system-wide impact of transition interventions on achieving value-based and sustainable health outcomes for all adolescents)

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 Bennett, A. L., Moore, D., Bampton, P. A., Bryant, R. V., & Andrews, J. M. (2016). Outcomes and patients’ perspectives of transition from paediatric to adult care in inflammatory bowel disease. World Journal of Gastroenterology. doi: 10.3748/wjg.v22.i8.2611.

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.