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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 + Integration into Adult Care

Approach. Provide planning, transfer assistance, and integration into adult care activities 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. Interventions that combine planning for transition, transfer assistance, and integration into adult care represent a comprehensive approach that addresses multiple stages of the healthcare transition process. Research indicates that using multiple elements of a transition strategy can be effective in achieving successful transition to adult care, with each component reinforcing the others.[1-5] Planning for transition includes disease education and skill-building activities that prepare youth and families for increased self-management, along with development of a plan of care, medical summary, and electronic medical information that can follow the youth into adult care. Transfer assistance encompasses identifying appropriate adult providers, providing scheduling assistance, and ensuring that transfer summaries are sent from pediatricians and shared with new adult providers to facilitate continuity. Integration into adult care involves structured processes including welcome and orientation to the new care environment, scheduling assistance and follow-up after the first adult visit, and ongoing monitoring of appointments to prevent gaps in care.[1-5] This three-component model recognizes that successful transition requires not just planning or finding a new provider, but comprehensive support through each phase of the journey. Title V programs can implement this approach through transition coordinators who shepherd youth through all three stages, ensuring no component is neglected.

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 communication 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. There are currently no ESMs that use this strategy. Search similar intervention components in the ESM database.

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 comprehensive transition planning services, including 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 integration into adult care activities implemented, including welcome/orientation process, scheduling assistance, follow-up after the first adult visit, and monitoring of appointments. (Measures the extent and continuity of support provided during the initial phases of adult care)

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

  • Percent of transition planning, transfer assistance, and integration into adult care services that align with national guidelines, evidence-based practices, and quality standards. (Measures the adherence and fidelity of transition interventions to best practices)
  • Percent of adult care providers and settings that have established policies, protocols, and resources to welcome, orient, and integrate transitioning adolescents into their practice. (Measures the readiness and capacity of adult care systems to provide developmentally appropriate and supportive services)

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

  • Number of multi-sector transition teams and networks formed, involving Title V programs, pediatric and adult health systems, payers, schools, social services, and community organizations, to provide coordinated and comprehensive transition support. (Measures the level of cross-sector collaboration and collective impact)
  • Number of transition-focused training programs, tools, and resources developed and disseminated to build the capacity of pediatric and adult providers to deliver effective transition services. (Measures the efforts to enhance the transition competencies and practices of the health care workforce)
  • Number of adolescents from communities who receive transition support leading to reduced gaps in care and improved health outcomes. (Measures the impact of transition interventions on advancing health)
  • Number of successful transition models, innovations, and lessons learned shared and replicated across states, health systems, and communities to accelerate the spread and scale of evidence-based transition practices. (Measures the potential for diffusion and sustainability of effective transition interventions)

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

  • Percent of transition planning, transfer assistance, and integration into adult care services that are designed and delivered in partnership with adolescents, families, and community members from multiple backgrounds. (Measures the level of authentic engagement and co-production of transition interventions with affected populations)
  • Percent of transition-related data collection, analysis, and reporting that is stratified by demographic variables to identify and address differences in transition outcomes. (Measures the use of data and evidence to drive quality improvement and accountability in transition services)
  • Percent reduction in differences in transition outcomes (e.g., care continuity, patient experience, health status) between adolescents from groups who may need additional support and those from groups who are not. (Measures the impact of transition interventions on eliminating unjust and avoidable differences in transition success and well-being)
  • Percent of adolescents, particularly those with complex health and social needs, who report increased resilience, self-determination, and sense of belonging as a result of the support, and empowerment provided through transition interventions. (Measures the impact of transition interventions on building the assets and agency of youth who may need additional support)

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 Essaddam L, Kallali W, Jemel M, et al. Implementation of effective transition from pediatric to adult diabetes care: epidemiological and clinical characteristics-a pioneering experience in North Africa. Acta Diabetologica. 2018;55(11):1163‐1169. doi:10.1007/s00592-018-1196-x.

2 Jones MR, Robbins BW, Augustine M, Doyle J, Mack-Fogg J, Jones H, White, PH. Transfer from pediatric to adult endocrinology. Endocrine Practice. 2017;23(7):822–830. https://doi.org/10.4158/EP171753.OR.

3 Kosola S, Ylinen E, Finne P, Ronnholm K, Fernanda O. Implementation of a transition model to adult care may not be enough to improve results: National study of kidney transplant recipients. Clinical Transplantation. 2018;33(1):p.e13449-n/a. https://doi.org/10.1111/ctr.13449.

4 Mackie AS, Rempel G, Kovacs AH, Kaufman M, Rankin KN, Jelen S, Hons B, Yaskina M, Sananes R, Oechslin E, Dragieva D, Mustafa S, Williams E, Schuh M, Manlhiot C, Anthony S, Magill-Evans J, Nicholas D, McCrindle BW. Transition intervention for adolescents with congenital heart disease. Journal of the American College of Cardiology. 2018;71(16):1768-1777. https://doi.org/10.1016/j.jacc.2018.02.043.

5 White M, O’Connell MA, Cameron FJ. Clinic attendance and disengagement of young adults with type 1 diabetes after transition of care from paediatric to adult services (TrACeD): a randomised, open-label, controlled trial. The Lancet Child & Adolescent Health. 2017;1: 274–283.

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.