Special Health Issues
What is Transition?
The US Department of Health and Human Services’ Maternal and Child Health Bureau defined transition of one of six national and state performance outcomes necessary to create a comprehensive system of services for all children with special health care needs. This outcome calls for all youth with special health care needs (YSHCN) to receive services needed to make necessary transitions to all aspects of adult life, including health care, work, and independent living.
Transition planning has also been recognized as an essential medical home element in the National Committee on Quality Assurance’s Patient-Centered Medical Home Standards, the Affordable Care Act, and Healthy People 2020.
In 2011, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians issued a joint clinical report on transition, which provides practice-based implementation strategies starting at age 12 and continuing to age 21.1
The goal of transition is to enable all youth/young adults, including those with special needs, to optimize their health, effectively manage their chronic condition, and transfer to an adult-focused medical home model of care without disruptions in care.
The National Health Care Transition Center (NHCTC), with funding support from the Maternal and Child Health Bureau, has developed a set of clinical tools and resources to assist medical home teams in implementing the 2011 joint clinical recommendations on transition. In the District of Columbia, The National Alliance to Advance Adolescent Health, with funding support from the DC Department of Health and the NHCTC, has been the first site in the country to implement and evaluate a 2-year transition quality improvement project for Medicaid-insured youth with special health care needs.
Samples of clinical tools and resources used by pediatric, family medicine, and internal medicine sites in DC are available at www.dctransition.org and described in the pages that follow.
1 American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Transitions Clinical Report Authoring Group. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011; 128 : 182-200.