Table 1.

Actions for implementing a structured pediatric-to-adult HCT process

Transition planning during pediatric care	Transfer	Integration into adult care
• Development of the practice's transition policy to share with youth/family • Transition readiness skill assessment and education • Preparation/update of medical summary and emergency care plan • Preparation of plan of care with HCT goals for youth with special health care needs • Referral, if needed, for supported decision-making • Discussion and practice of an adult model of care at age 18 • Assistance with identifying an adult clinician • Preparation of transfer package • Outreach for pediatric appointment adherence • Sequenced transfers (if seeing multiple clinicians) • Consultation support to adult clinicians, if needed • Youth/family feedback	• Transfer package exchange • Communication/confirmation between pediatric/adult clinicians • Clarification of residual role responsibility prior to initial visit with adult clinician • Communication and education with transferring young adult	• Development of a transition policy for accepting young adult (YA) patients into the practice, and sharing of the policy with YA/family. • Identification of adult clinicians in practice to care for YAs • Preparation of FAQs and orientation information for YAs • Pre-visit outreach and appointment reminders • Review of new patient records • Initial face-to-face visit with YA • Update of medical summary • Medication reconciliation • Update of plan of care (especially for those with special health care needs) • Self-care skill assessment and education • Assistance in establishing referrals for medical specialists/behavioral health/reproductive care/community supports
Ages 12–21	Ages 18–22	Ages 18–26

Resources and tools to implement a structured transition process are included in Got Transition's Six Core Elements of Health Care Transition. Six Core Elements packages are available for different clinical settings (pediatrics, family medicine, med-peds, and internal medicine). The customizable packages as well as implementation guides can be downloaded for free on Got Transition's website at www.GotTransition.org.