Evidence Tools
MCHbest. Transition.

Overview. Combining transfer assistance with integration into adult care creates a critical bridge for youth moving from pediatric to adult healthcare systems. Multicomponent interventions continue to grow in prominence and show value in improving transitions to adult health care through coordinated support across the transfer period.[1] Transfer assistance elements include providing letters of referral and coordination of referrals between pediatric and adult providers, as well as transfer summaries that communicate essential medical information to the new adult care team. Integration into adult care involves structured processes such as self-care skills assessment, welcome and orientation procedures, and ongoing monitoring to ensure successful engagement with the new provider. A coordinated care pathway that includes specialized pediatric care leading to a multidisciplinary adult team accustomed to managing complex disability can be associated with better health status and sustained engagement in care.[1] Title V programs can facilitate these transitions by developing partnerships between pediatric and adult care systems, creating standardized communication protocols, and supporting transition navigators who guide youth through the transfer process. This two-component approach addresses both the logistical challenges of finding and connecting with adult care and the adaptation challenges of integrating into a new care environment.

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 on transfer and integration experiences
• Adult provider reports on preparedness and integration
• Evaluation data related to transfer completion and adult provider enrollment rates

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).