This is the most critical part and where the ball gets dropped or people can fall through the cracks. THe main objectives here are:
- Complete transfer package, including final transition readiness assessment, plan of care with transition goals and prioritized actions, medical summary and emergency care plan, and, if needed, legal documents, condition fact sheet, and additional clinical records .
- Confirm date of first adult clinician appointment. • Prepare letter with transfer package, send to adult clinician, and confirm adult clinician’s receipt of transfer package.
- Communicate with selected adult clinician about pending transfer of care .
- Confirm the pediatric clinician’s responsibility for care until youth/young adult is seen by an adult clinician.
- Transfer youth/young adult when their condition is as stable as possible
Transfer of Care
Transfer of care is the fifth element in the Six Core Elements of Health Care Transition™ (HCT). Establishing a systematic method for transfer to an adult clinician ensures that key tasks are accomplished; that youth, young adults, and parents/caregivers are informed of and involved in the hand-off of care and current medical information; and that communication and coordination between pediatric and adult clinicians takes place. For youth and young adults with special health care needs, transfer of care often requires coordination among multiple clinicians to ensure a safe and continuous process. Transfer to an adult clinician is recommended before the age of 22.
