Table 3.

The Six Core Elements approach for pediatric and adult practices

	Transition and/or care policy	Tracking and Monitoring	Transition Readiness and/or orientation to adult practice	Transition planning and/or integration into adult approach to care/practice	Transfer of care and/or initial visit	Transition completion or ongoing care
Existing Six Core Elements Framework from Literature [17]	• Create and discuss with youth/young adult and/or family	• Pediatric: Track progress of youth and/or family transition preparation and transfer at the pediatric side • Adult: Track progress of young adult’s integration into adult care	• Pediatric: Conduct transition readiness assessments • Adult: share and discuss welcome and FAQ’s with young adult and guardian, if needed	• Pediatric: Develop transition plan including needed skills and medical summary, prepare youth for adult approach to care and communicate with new clinician • Adult: Communicate with previous clinician, ensure receipt of transfer package	• Pediatric: Transfer of care with information and communication including residual pediatric clinician’s responsibility • Adult: Review transfer package, address young adult’s needs and concerns at initial visit, update self-care assessment and medical summary	• Pediatric: Obtain feedback on the transition process and confirm young adults has been seen by the new clinician • Adult: Confirm transfer completion with previous clinician, provide ongoing care with self-care skill building and link to needed specialists
Stakeholders Proposed Strategies and Intervention Characteristics	• Transition policy needs to be clear, consistent, and well-explained		• Transition preparedness starts at an early age • Prepare caregivers to “let go” to build patient autonomy	• Ensure AYA-SCD specific challenges are well-communicated and addressed • Ensure inter-organizational and patient-provider communication	• Care coordination: co-location of care or a transition care coordinator • Provide incentives (i.e. food) to increase program attractiveness • Improve patient-provider communications	• Peer mentorship could be helpful • Identify program champions and provide ongoing patient advocacy
Changes Made	• Local practice and resource mapping • Established clearer transition policy and assigned responsibilities • The social worker created a resource guide	• The pediatric and adult hematology teams started bimonthly joint transition meetings	• A transition letter for pediatric patients aged 14 • Engaged patients and caregivers in the transition program planning and adjustments • Implemented clinic-based transition assessment and educational intervention to improve transition skills[28]	• Pediatric hematologists extended care to young adults patients with SCD • Bimonthly joint transition meetings	• Pediatric hematologists extended care to young adults patients with SCD • Implemented transition package for all transition patients • Bimonthly joint transition conference • Adult social worker meets with patient in pediatric setting prior to transition	• Continued advocacy for patients and caregivers
Additional Changes	• The institution hired one new adult hematologist and a social worker for the adult team • Improve adult Emergency Department care through establishing more standardized pain treatment practice and address stigma related to patients with SCD