There is a great guide for this function in the “Materials” folder at the top of this page. 
Here is an excerpt.

The Objectives for Ongoing Care:

  • Communicate with pediatric practice confirming completion of transfer into adult practice and consult with pediatric clinician(s), as needed .
  • Assist young adult in connecting with adult specialists, as needed, and provide linkages to insurance resources, self-care management information, and community support services . • Obtain consent from young adult for release of medical information .
  • Continue with ongoing care management tailored to each young adult and their cultural preferences .
  • Elicit anonymous feedback from young adult on their experience with the transition process .
  • Build ongoing and collaborative partnerships with other primary and specialty care clinicians .

Remember, it is a process that can be improved. Use the Implementation Plan tools to be sure you are improving your practice and accommodating the patients and the system, to reduce morbidity, mortality, and costs.