Understanding the Six Core Elements
The Six Core Elements of Health Care Transition is a widely adopted approach created by Got Transition®, an initiative of the National Alliance to Advance Adolescent Health. This framework provides a clear roadmap for healthcare professionals, patients, and families to manage the complex process of shifting care, especially for youth with chronic health conditions.
1. The Practice's Transition Policy
Every practice or clinic should have a written policy detailing its approach to transition. This policy outlines when the transition process should begin (typically starting around age 12-14), what it involves, and the roles of the patient, family, and medical staff. It sets clear expectations for everyone involved and provides a transparent framework for the entire journey. A strong policy ensures consistency and reduces anxiety for young adults and their families.
2. Transition Tracking and Monitoring
Effective transition relies on careful monitoring of patient progress. This involves using electronic medical records or other tracking systems to identify patients approaching transition age and to follow their progress. Tracking ensures that no patient falls through the cracks and that all necessary steps, such as readiness assessments and planning sessions, are completed in a timely manner.
3. Transition Readiness Assessment
Assessing a young person's readiness for managing their own health is a crucial step. Starting around age 14, standardized questionnaires are used to evaluate the patient's self-care skills and knowledge about their health condition. These assessments cover topics such as understanding medication schedules, managing appointments, and communicating with providers. The results help healthcare teams tailor their support and education to meet the patient's specific needs.
4. Transition Planning
Developing an individual transition plan is a collaborative process involving the patient, family, and healthcare team. This plan is designed to empower the young adult to manage their own healthcare as independently as possible. A comprehensive plan includes a detailed medical summary, emergency contacts, a list of adult-focused specialists, and a timeline for the transfer. Planning visits are used to review the patient's understanding of their condition and their skills for self-management.
5. Transfer of Care
The actual transfer of care involves moving the patient from the pediatric practice to a new adult-centered practice. This step should occur when the young person is ready, typically between the ages of 18 and 21. Before the transfer, the pediatric team compiles all necessary transfer documentation, including the medical summary and care plan, and sends it to the new provider. It is important to remember that until the first visit with the new provider is completed, the pediatric team remains responsible for the patient's care.
6. Transition Completion and Follow-up
The final element is confirming that the transition is complete and successful. This involves following up with the patient and family to ensure the new care arrangement is working well. Feedback from the consumer—the young adult patient—is essential for evaluating the success of the process and identifying areas for improvement in future transitions. This step closes the loop, celebrating the patient's new-found independence in their health management.
Comparison: Pediatric vs. Adult Care
| Feature | Pediatric Care | Adult Care |
|---|---|---|
| Focus | Family-centered, with parents/guardians as primary decision-makers. | Patient-centered, with the individual taking the lead on decisions. |
| Communication | Clinicians communicate primarily with parents, who then manage care. | Clinicians communicate directly with the patient. |
| Appointments | Parents typically schedule and accompany the child to appointments. | The patient is responsible for scheduling appointments and attending independently. |
| Decision-Making | Parents have legal authority over medical decisions. | The patient has legal authority and responsibility for their medical decisions. |
| Environment | The clinical environment is often designed to be kid-friendly. | The clinical environment is generally designed for adults, with less emphasis on a family setting. |
Practical Steps for a Successful Transition
For young people and their families, navigating this process requires proactive engagement. Here are some actionable steps:
- Start early: Begin discussing the transition process with your pediatric care team and family when the young person is a pre-teen. This provides ample time to build self-management skills.
- Build skills incrementally: Teach the young person how to communicate with doctors, manage their medications, and understand their health condition over time. Don't wait until the last minute.
- Maintain open communication: Ensure transparent conversations among the young adult, parents, and healthcare providers. Address concerns and set goals together.
- Utilize readiness tools: Take advantage of the readiness assessments offered by your clinic to identify areas where more education or skill-building is needed.
- Keep comprehensive records: Compile a complete medical summary that includes all diagnoses, medications, allergies, and specialist information to ease the transfer to a new provider.
- Research adult providers: Look for adult-focused specialists who have experience with the patient's specific health condition before the transfer date.
Conclusion: Empowering Independence
The Six Core Elements are more than just a procedural checklist; they are a vital strategy for empowering young people with chronic conditions to take charge of their health and well-being as they enter adulthood. By following this structured approach, healthcare providers can facilitate a seamless and safe transition, ensuring that patients not only have access to adult care but also the skills and confidence to manage it effectively. The result is a healthier, more independent patient who can successfully navigate the healthcare system for the rest of their life. For more resources on this topic, visit the official Got Transition website.
Got Transition®: The National Resource Center for Health Care Transition
