Descriptions
The practice involves the patient/family/caregiver in the development or implementation of a written care plan for young adults and adolescent patients with complex needs transitioning to adult care. The written care plan may include:
- A summary of medical information (e.g., history of hospitalizations, procedures, tests).
- A list of providers, medical equipment and medications for patients with special health care needs.
- Obstacles to transitioning to an adult care clinician.
- Special care needs.
- Information provided to the patient about the transition of care.
- Arrangements for release and transfer of medical records to the adult care clinician.
- Patient response to the transition.
- Patient transition plan.
Internal medicine practices receiving patients from pediatricians are expected to request/review the transition plan provided by pediatric practices or develop a plan if one is not provided to support a smooth and safe transition.
For family medicine practices that do not transition patients from pediatric to adult care, should still educate patients and families about ways in which their care experience may change as the patient moves into adulthood. Sensitivity to privacy concerns should be incorporated into messaging.