Step 9: Tips for Success

 Make sure there is a champion for transition improvement in the practice.

• Select which of the Six Core Elements to use based on your practice’s needs and

capacities.

• Do not try to do too much too quickly. Practices that try to implement too many

changes at once risk doing none of them well. Do not lose sight of the fact that your

long-term goal is to redesign your systems to improve patient care, which takes longer

than making incremental changes.

• Develop a registry so the team can keep track of the activities being offered to which

youth/young adults.

• Connect with other transition improvement efforts regionally and/or nationally to learn

and share best practices.

• Do not forget to measure and track progress for each core element. This step is critical

to help you implement successful transition changes in your practice.

• Linking implementation activities for two or more of the Six Core Elements can foster

efficiencies and bring about added clarity and connectedness for your practice staff.

• Choose Core Elements that can build on or complement other QI and/or practice

transformation efforts, such as Patient-Centered Medical Home certification.

Connecting these efforts can help staff to see transition work as a logical extension to

existing efforts.

• Communicate progress regularly. Ways to do this include updates at staff and team

meetings, posters in the waiting room explaining the project, participation in a learning

collaborative, or direct reporting to a practice improvement committee. These activities

can help build and support for this work.

• Plan a process that starts early (ages 12-14), but also plan a fast track process for “20-21

year olds” still in the pediatric system who need to transfer within the next year.

• It is important to have early wins to test the process. Consider not beginning with

youth/young adults with complex conditions as the initial pilot population as they often

require multiple transfers.

1 White, PH, Cooley, WC, Transitions Clinical Authoring Group, American Academy of Pediatrics, American Academy of Family

Physicians, & American College of Physicians. Supporting the health care transition from adolescence to adulthood in the

medical home. Pediatrics. 2018;142(5):e20182587.

2 Schmidt A, Ilango SM, McManus MA, Rogers KK, White PH. Outcomes of pediatric to adult health care transition interventions:

An updated systematic review. Journal of Pediatric Nursing. 2020;51:92‐107.

3 McManus M, White P, Schmidt A, Kanter D, Salus T. 2020 Coding and Reimbursement Tip Sheet for Transition from Pediatric to

Adult Health Care. Washington, DC: Got Transition and American Academy of Pediatrics, March 2020.