Outpatient Specialty Care and Primary Care Clinical Pathway
for Children Transitioning to Adult Care
For Institutions or Divisions Interested in Developing a Transition Program
- Discuss Transfer of Care with Patient/Family
- Review Division Policy if applicable
- Every effort should be made for patients to be transitioned to adult care by age 21
- Review Hospital Admission Policy
- Add “Counseling for Transition” to Problem List
- Review Patient Education as needed
- Begin to see patient alone for part of visit to facilitate healthcare independence
- Review Division Policy if applicable
- Assessing Transition Readiness
- Complete or Review Readiness Assessment (TRAQ) Screenshots
- Transition Readiness Assessment Questionnaire
- Note: If interested in EPIC tools for transition support including the TRAQ, contact IS support
- Consider Social Work Consult
- For example: Health Insurance, Intellectual Disability,
Medical Decision Making Concerns, and Mental Health Diagnoses - Process for Healthcare Independence
- For example: Health Insurance, Intellectual Disability,
- Consider Adult Care and Transition Team (ACTT) Consult
- Note: ACTT consult can be placed for patients who are ≥ 18 years with two or more subspecialists and/or with an intellectual disability.
- Creating a Transfer Plan
- For providers: Recommendations for content to include in final clinic
note or letter- Create “Health Summary for Transition of Care” letter
- For patients: Steps for finding an adult provider and insurance
- Coordinate appointments with new providers
- For providers: Recommendations for content to include in final clinic
- Implementing a Transfer Plan
- Epic communications with new provider
- Provide patient and new providers with a copy of the transition summary
- Update problem list with new provider information
- Confirm transfer with all providers and patients
Posted: December 2017
Revised: October 2022
Authors: D. Szalda, MD; A. Greenberg, NP; N. Stollon, MSW; S. Quinn, MD; S. Trachtenberg, MSW LSW
Revised: October 2022
Authors: D. Szalda, MD; A. Greenberg, NP; N. Stollon, MSW; S. Quinn, MD; S. Trachtenberg, MSW LSW