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New Tip Sheet Links 2017 Patient-Centered Medical Home Standards with Six Core Elements

Got Transition released a new tip sheet to help practices incorporate transition as part of their application process for becoming a patient-centered medical home (PCMH).   Using the 2017 Standards for Patient-Centered Medical Home Recognition from the National Committee for Quality Assurance (NCQA), this practice resource includes a table that cross-walks NCQA PCMH criteria and guidance with specific linked Six Core Elements tools. Click HERE for the tip sheet.

Free CME Podcast on Transition

Dr. Patience White sat down with Dr. Mike Patrick, host of PediaCast CME from the Nationwide Children's Hospital, to talk about health care transition and the Six Core Elements. The hour-long podcast, "Transitioning Pediatric Patients to Adult Health Care," describes the design and implementation of a transition program within a clinical practice to ensure a smooth transition for pediatric patients. It is intended for primary care physicians, pediatric subspecialists, and other health care professionals who provide care for pediatric patients. Listeners can take a short Post Test to receive their free Continuing Medical Education (CME) credit.

NCWD Releases Young Person's Guide to Health Care Transition

A Young Person's Guide to Health Care Transition is a report from the National Collaborative on Workforce and Disability that speaks directly to youth about moving from pediatric to adult health care. The report considers topics such as changing providers, living a healthy lifestyle, paying for health care, and managing their own health and wellness. "Taking charge of your health care transition goes hand in hand with helping you achieve your career and life goals."

New Report on Innovative State Tile V Transition Efforts

A new Got Transition report, “Transition to Adult Health Care and State Title V Program Directions: A Review of 2017 Block Grant Applications” examines the FY 2017 state Title V block grant applications from 32 states that selected the transition national performance measure. This report presents current information about state Title V transition strategies and evidence-informed measures. It provides examples of innovative transition strategies, recommendations for states, and information about the new transition measure from the National Survey of Children’s Health that will be used to report state and national transition performance.

Free Pediatric Maintenance of Certification Transition Module Available

The University of California San Diego/Rady Children’s Hospital with the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) partnered with Got Transition to develop a new pediatric Maintenance of Certification (MOC) Part 4 Module on transition. The web-based activity – “Transitioning Youth from Pediatric to Adult-Centered Care – will evaluate adequacy of participant documentation of patients' transition from pediatric to adult centered care within the 6 Core Element framework developed by Got Transition: Center for Health Care Transition Improvement. Eligible participants include clinicians who actively evaluate pediatric patients with chronic diseases on a frequent enough basis to report data on 30 patient visits over a year period. This activity will provide MOC Part IV credits to participants who successfully meet completion criteria. To learn more about completion criteria and to register for FREE, email Kim Rose (KRose@naspghan.org) by March 31, 2017 and mention “GotTransition.org/UC San Diego/Rady Children’s Hospital."

Earn CME Credits in Transition

Health Services for Children with Special Needs (HSCSN) is offering a free online one-hour CME course on health care transition. The one-hour CME features the experiences of physicians in busy pediatric, family medicine, and internal medicine practices in the District of Columbia who successfully implemented the Six Core Elements using quality improvement methodologies. The course was developed in collaboration with The National Alliance to Advance Adolescent Health/Got Transition, HSCSN, and the DC Department of Health.

Two Reports on 32 States Selecting Health Care Transition as a State Public Health Priority

A new Got Transition report, “State Title V Health Care Transition Performance Objectives and Strategies: Current Snapshot and Suggestions,” analyzes the FY 2016 State Title V Action Plans from the 32 states that have selected transition as one of their priorities to address over the next five years. The report offers specific suggestions for 1) aligning transition objectives with the new transition measure in the upcoming National Survey of Children's Health and the Six Core Elements of Health Care Transition, and 2) selecting measurable strategies related to expanding availability of adult providers, assessing health care transition implementation, and increasing quality improvement and educational efforts using the Six Core Elements. 

Got Transition has also released a report, “Aligning National Title V Performance Measures on Transition, Medical Home, Preventive Care, and Insurance: Suggested Strategies for States,” which offers strategies to state Title V agencies and their partners on linking performance improvements and innovations for transition with medical home, adolescent well care, well care for women, and adequate health insurance. 

Incorporating Transition into Epic Electronic Health Record Software: A Survey of Expert Users

Got Transition’s newest report, Incorporating Transition into Epic Electronic Health Record Software: A Survey of Expert Users, discusses ways of incorporating the Six Core Elements of Health Care Transition into Epic. This report is only available to Epic users and can be accessed using your Epic UserWeb login credentials by clicking HERE.

Editorial on Adolescent Engagement and Transition in JAH

In the September issue of the Journal of Adolescent Health, Margaret McManus explains the importance of adolescent engagement in health care. The editorial emphasizes the need to improve measurement of adolescent engagement and references Got Transition’s new transition readiness assessment tool.  It also calls for health plans and providers to consider the continuum of adolescent engagement pertaining to direct care as well as to involvement of youth as staff, peer educators, advisory group members, and other leadership positions. Read the editorial here.

Got Transition’s New Home

The National Alliance to Advance Adolescent Health is the new “home” for Got Transition’s Center for Health Care Transition Improvement. With funding support from the Maternal and Child Health Bureau, Got Transition will focus on 1) quality improvement spread using the Six Core Elements of Health Care Transition, 2) health care professional training, 3) youth and family engagement, 4) policy improvements, and 5) information dissemination. Read the press release for more information.

Six Core Elements 2.0

Got Transition launches its new website and releases the new Six Core Elements of Health Care Transition (2.0) with corresponding clinical tools and measurement resources. There are three sets of customizable tools available for different practice settings: 1) transitioning youth to adult health care providers, 2) transitioning to an adult approach to health care without changing providers, and 3) integrating young adults into adult health care. Aligned with the AAP/AAFP/ACP Clinical Report on Transition, the Six Core Elements are intended for use in primary and specialty settings. Originally developed in 2009, this updated version incorporates the results of several transition learning collaboratives, an examination of transition innovations in the U.S. and abroad, and reviews by over 50 pediatric and adult health care professionals and youth and family experts. See the Health Care Providers section for more information about the new Six Core Elements.

Transition as MCHB National Performance Measure

Transition from pediatric to adult health care has been proposed as one of the Maternal and Child Health Bureau’s national performance measures. Stay tuned to the MCHB website for an announcement.

Employment & Transition Partnerships

Got Transition has formed a new partnership with the Department of Labor’s Office of Disability Employment Policy and the HSC Foundation’s Youth Transitions Collaborative to disseminate career planning and health care transition resources and to identify and develop resources and educational opportunities related to health care and employment transition planning.

ADAPT Survey Tool Available

A new validated survey instrument is available to measure the quality of transition preparation among youth, ages 16 and 17, with chronic conditions. The Adolescent Assessment of Preparation for Transition (ADAPT) survey was developed by the Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital. This 26-item survey of youth addresses key domains in health care transition preparation:  receipt of counseling on transition self-management, prescription medication, and transfer planning. This new survey, available also in Spanish, can be used in clinical settings or by health plans.  Click here for more information on how to access the ADAPT survey.

New Fact Sheets on ACA Provisions

The Catalyst Center and National Center for Medical Home Implementation have released four fact sheets that explain specific provisions of the Affordable Care Act which benefit children and youth with special health care needs. Topics include Concurrent Care for Children; Habilitative Services; Health Home Programs and Coordinated Care; and Health Insurance Marketplace and Medicaid Coverage for Children with Disabilities. You can find all four sheets here.

Federal Interagency Strategy for Transition Published

The Federal Partners in Transition Workgroup (which includes the Departments of Labor, Education, Health and Human Services, and the Social Security Administration) released its The 2020 Federal Youth Transition Plan: A Federal Interagency Strategy. The plan provides recommendations for federal cross-system initiatives on transition related to community engagement, education, employment, health, and independent living. Recommendations related to health care include facilitated access to quality health care and health care insurance, health professional development on asset-based delivery approaches, and creation of a benefits counseling model that promotes self-determination and person-centered planning.

Transition Quality Improvement Results

Substantial  improvements were made in transition clinical processes in both pediatric and adult practices using the Six Core Elements of Health Care Transition, according to a study published in the Journal of Adolescent Health.  As the first transition quality improvement project evaluating the use of the Six Core Elements, these positive results indicate the feasibility of an organized transition process.   The participating practices were large DC-based pediatric and adult academic health care centers participating in a 2-year learning collaborative directed by The National Alliance to Advance Adolescent Health. Read the article here.

The National Alliance to Lead Transition Payment Roundtable

The Lucile Packard Foundation for Children’s Health recently funded The National Alliance to lead an expert committee of public and private payers and health plan leaders to develop recommendations and action steps for advancing payment innovations in pediatric-to-adult transition care. This one-year effort will result in strategic guidance to build high-level support among payers and plans to incorporate transition into payment innovations and to encourage the recognition of transition-related services in both pediatric and adult care settings. To read more about the transition payment roundtable, click here.

New 2017 Transition Coding and Reimbursement Tip Sheet Available

Got Transition and the American Academy of Pediatrics released a new 2017 Transition Coding and Reimbursement Tip Sheet to support the delivery of recommended transition services in pediatric and adult primary and specialty care settings. The new tip sheet includes a list of updated transition-related CPT codes, including the new code for transition readiness assessment, and current Medicare fees and RVUs for these services.  It also includes a new set of seven clinical vignettes with recommended CPT and ICD-10 codes. Click HERE for the tip sheet.

UCLA Receives Autism Transition Research Network Grant

The Maternal and Child Health Bureau awarded UCLA’s Center for Healthier Children, Families and Communities a three-year grant to establish a national Health Care Transitions Research Network for individuals with autism spectrum disorder (ASD).  Dr. Alice Kuo, the associate director of the Center,  is leading this new initiative, which includes the development of an interdisciplinary, multi-center research forum for scientific collaboration focusing on improving the physical, psychosocial, educational, and vocational outcomes for youth and young adults with ASD. Click here to find out more.

New National Young Adult Transition Advisory Group Formed

Got Transition has created a new National Young Adult Transition Advisory Group to advise the organization on young adult perspectives on health care transition. The advisory group consists of young adults with and without disabilities between the ages of 18-25 that come from diverse geographic locations and ethnic backgrounds. They all represent various state and national health-related organizations around the country. The Young Adult Transition Advisory Group will ensure that young adult consumer perspectives are included in Got Transition’s plans moving forward. They will help review tools designed to educate and inform young adults on the importance of health care transition, guide Got Transition’s social media platforms to relay important health care transition-related messages and resources to youth and young adults, and bolster Got Transition’s partnerships with their organizational affiliates.

New Report on Adolescent and Young Adult Insurance Confidentiality

With the extension of dependent coverage to age 26 under the Affordable Care Act, 8 million adolescents and young adults aged 19-26 years are now covered by their parent's insurance. However, this expanded coverage has implications for patient confidentiality, as issuance of explanation of benefit (EOB) statements by insurers can compromise patient privacy, and in doing so, discourage or delay needed care.   


States Offer Privacy Protections to Young Adults on Their Parents' Health Plan
, a report by Kaiser Health News, looks at reforms of state laws and insurer billing practices to prevent breeches of confidentiality. In recent years, California, Colorado, Washington, Oregon, and Maryland have taken steps to improve health insurance confidentiality protections, both through legislation and insurance commissioner actions.

ACP Releases New Transition Tools for Pediatric to Adult Health Care Transition

Dr. Wayne Riley, the President of the ACP, and Dr. Carol Greenlee, the chair of ACP’s Transitions Initiative, announced the release of specialized toolkits to facilitate more effective transition and transfer of young adults into the adult health care setting at the ACP’s 2016 Annual Meeting in Washington, DC. The new transition toolkit contains condition-specific tools, including transition readiness assessments, self-care assessments, and medical summaries customized from Got Transition’s Six Core Elements of Health Care Transition. Transition tools are available for the following subspecialties and diseases: general internal medicine (intellectual/developmental disabilities and physical disabilities), cardiology (congenital heart disease), endocrinology (type 1 diabetes, turner syndrome, growth hormone deficiency), gastroenterology (inflammatory bowel disease is coming soon), hematology (general hematology, sickle cell disease, hemophilia), nephrology (end-stage renal disease), and rheumatology (juvenile idiopathic arthritic, systematic lupus erythematosus). This ACP Transitions Initiative was a collaborative effort with Got Transition/Center for Health Care Transition Improvement, the Society of General Internal Medicine, and the Society for Adolescent Health and Medicine.

College Medical Directors Call for Better Approach to Transition

In the November issue of Pediatrics, Boston Children’s Hospital and Dartmouth authors report on the results of a national survey of medical directors from four-year colleges.  Lemly et al. found that medical directors receive variable health information for incoming youth, most often immunization records, a medical history form completed by students, and proof of insurance.  Few colleges systematically identify and track youth with special needs or receive medical records or communication from incoming student’s primary care providers.  The study concluded with the need to “further involve and integrate college health in the national discussion about improving health care transitions of youth with special needs.”   Read the article here.

Transition Planning Impacts

Published studies have shown that transition planning from pediatric to adult health care is associated with improved outcomes. These include reduced medical complications, better patient-reported outcomes, greater adherence to care, improved continuity of care, positive patient experience, and lower costs. Click here to see the list of published studies

Clinical Report on Transition Reaffirmed

The clinical report, “Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home,” from the American Academy of Pediatrics, American Academy of Family Physicians,  and American College of Physicians, originally published in 2011, received a statement of reaffirmation in the November 2015 issue of Pediatrics. It provides detailed guidance on how pediatricians, family physicians, and internists can incorporate better transition supports into their busy practices for all adolescents, including those with special health care needs, as they transition to an adult model of health care. The report calls for all transitions in care to be based on adequate preparation, proactive communication, and early engagement of patients, families, and referring and accepting physicians. It also provides strategies  to overcome common challenges, including an algorithm to guide physicians through the transition process. Got Transition's Six Core Elements of Health Care Transition were aligned with the 2011 clinical report.

Got Transition in the Wall Street Journal!

In the "Informed Patient" column on the front page of the Wall Street Journal's Personal Journal section, Laura Landro discusses the challenges of transitioning young adults from pediatric to adult health care, especially for those youth with special health care needs. The article highlights the work of Got Transition in addition to Nemours/Alfred I. duPont Hospital for Children, the Society of General Internal Medicine, and the Endocrine Society. Click here to read the article and learn more!

Tip Sheet for Adult Providers Integrating Young Adults with ID/DD into Their Practice

Got Transition has released a new tip sheet to guide adult health care providers in receiving new young adult patients with intellectual and developmental disabilities (ID/DD) into their practice.  Written by Dr. Carl Cooley of Crotched Mountain Foundation and Dartmouth’s Geisel School of Medicine and Dr. Thomas Cheetham of Tennessee’s Department of Intellectual and Developmental Disabilities and Vanderbilt University, this resource provides suggestions for preparing the office and staff for welcoming new young adults with ID/DD, including training and consumer engagement.  It also offers tips for what to do before, during, and after the young adult’s first visit.  Click here for the tip sheet.

Transition QuickGuide and Webinar on Health Care and Career Planning

Got Transition has partnered with the Office of Disability Employment (Department of Labor) and the Youth Transitions Collaborative to create a Transition QuickGuide for youth and young adults (ages 12-30), including those with disabilities and chronic health conditions. The QuickGuide includes information and resources about health insurance, self-care management, transition from pediatric to adult health care, decision-making, and career planning to help young people manage their health care needs in order to make their career goals a reality. A related joint letter from ODEP and HRSA’s Maternal and Child Health Bureau emphasizes the importance of expanding access to health care services and work-based experiences for youth with chronic health conditions and disabilities. Click here to read more.


This Alliance of organizations also hosted a webinar that discussed the importance of young adults managing their own health and career goals as they transition to adulthood. It included the personal experiences of Got Transition's consumer expert, Teresa Nguyen, as well as a young adult and parent team from the ODEP-funded National Collaborative on Workforce and Disability for Youth (NCWD/Youth)  YouthACT program. Click HERE to find a video of the webinar and its corresponding materials!

New Article on Transition Pilot in DC Medicaid Managed Care Plan

The Journal of Pediatric Nursing, in its recent volume on transition, includes a new Got Transition collaborative project with a DC-based Medicaid managed care plan that serves SSI eligible youth and young adults. The project involved customizing the Six Core Elements of Health Care Transition into the plan’s care management system and piloting it the transition model with young adults with chronic mental health, developmental, and complex medical conditions. The first-of-its-kind pilot project demonstrated an effective approach for delivering recommended transition services in a managed care plan. Read about the collaborative project here.

The National Alliance Receives Grant to Improve Transition in DC

The National Alliance to Advance Adolescent Health, the DC-based non-profit organization that operates Got Transition, was awarded a new grant by the DC Department of Health to expand health care transition training, services, and consumer leadership in Wards 7 and 8. The National Alliance will build partnerships with the DC Community Health Administration, the DC Department of Behavioral Health, MedStar Georgetown’s School Based Health Center at Anacostia High School, Health Services for Children with Special Needs, and the DC Department of Health Care Finance. Goals of the new project include extending training and quality improvement efforts, developing school and community leadership, and designing policy strategies to expand the availability of health care transition services. 

Special Report on America’s Young Adults

“America’s Young Adults” is a special report that highlights a broad set of indicators on transition to adulthood.  Published by the Federal Interagency Forum on Child and Family Statistics, a collaboration of 22 federal agencies, this report provides current data on the 18-24 year old population related to demographics, education, economic success, family support, civic/social/personal behavior, and health and safety.  A total of 31.2 million young adults are making the “complex journey” into adulthood.  Among this group, 58% are privately insured, only 15% are publicly insured, and as many as 25% are uninsured.  Importantly, also, 29% do not have a usual source of care.  Additional health and non-health data are available by gender, income, race and ethnicity, and more.  Click here to read the 2014 special report.

Tip Sheet Available for Transition Improvement Process

A practical set of steps and lessons learned for starting a Transition Improvement process is now available.  These tips have been learned from transition improvement projects across the country.  They are intended for use by pediatric, family medicine, and internal medicine primary care and specialty practices as well as by health systems, health plans, and payers in concert with the clinical tools and measurement resources available at Got Transition. Click here to access this new information.

A Systematic Review of Transition Measures and the “Triple Aim”

A new systematic review of transition measures, released in the December issue of Pediatrics by the Got Transition staff, found that transition intervention studies seldom consistently measure their impact in terms of the “Triple Aim” (consumer experience, population health, and costs of care).   A total of 33 studies, published between 1995 and 2013, met the systematic review criteria for inclusion. Of these, population health measures were used most frequently, typically in the form of disease-specific outcomes.   Service use and, to a less extent, costs of care were measured in about half of the studies.  Experience of care was measured in only one quarter of studies, most often in terms of care generally, not in terms of transition support specifically. Only 3 studies examined all 3 domains of the Triple Aim.  Read the article here.



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Got Transition™ is a program of National Alliance Logo The National Alliance to Advance Adolescent Health supported by U39MC25729 HRSA/MCHB