The main objectives in this stage are:
- Develop and regularly update the plan of care, including readiness assessment findings, youth’s goals and prioritized actions, medical summary and emergency care plan, and, if needed, a condition fact sheet and legal documents .
- Prepare youth and parent/caregiver for an adult approach to care, including legal changes in decision-making and privacy and consent, self-advocacy, and access to information . • Determine need for decision-making supports for youth and make referrals to legal resources .
- Plan with youth and parent/caregiver for optimal timing of transfer from pediatric to adult care . If both primary and subspecialty care are involved, discuss optimal timing for each
- Assist youth in identifying an adult clinician(s) and provide linkages to insurance resources, self-care management information, and community support services
- Obtain consent from youth/parent/caregiver for release of medical information .
- Take cultural preferences into account throughout transition planning
Transition planning is the fourth element in the Six Core Elements of Health Care Transition™ (HCT). Planning for transition should be accomplished in collaboration with youth and parents/caregivers beginning in early adolescence and continuing until the youth transfers out of pediatric care. Transition planning encompasses several ongoing activities that are intended to build health literacy and independent self-care skills; assist in preparing for changes that happen at age 18; and guide the timing of transfer and the selection of a new adult clinician, taking cultural preferences into account. In addition, addressing the legal issues of supported decision-making should be a part of this planning, if needed.
