Supporting Youth to Adult Health Care Transition

Z OLD page Resources for Health Care Providers and Systems

As a health professional who cares for young adults, whether you’re a physician, nurse, social worker, or any other type of professional, you play an important role in youth health transition! We hope the resources on this website are useful as you provide the care and guidance to help your patients lead healthy and productive lives as young adults.

This is an accordion element with a series of buttons that open and close related content panels.

Introduction to Youth Health Transition for Providers

Shared Plan of Care 2020 Quality Improvement Grants

Advancing Family-Centered Care Coordination for Children and Youth with Special Health Care Needs 2020 Shared Plan of Care Quality Improvement Grant Project  Go to our Quality Improvement Grants page for an overview of current grantees.

Got Transition & 6 Core Elements

The resources listed below relate to a variety of transition issues that health professionals can use to assist youth and families during transitional years.

Got Transition-Health Care Providers – Links to multiple Got Transition resources.

Confidentiality in Health Care:  Clinical Care Guidelines and Resources – From an initiative of the Society for Adolescent Health and Medicine (SAHM).

Condition Specific Tools

Have questions about a specific condition?

  1. Condition Specific Information
  2. Condition Specific Checklist

Learning Community

The Youth Health Transition Learning Community provides networking opportunities for health professionals who wish to move transition forward in their own organizations. This statewide group comes together virtually to share ideas and best practices around youth health transition. This webinar is for physicians, physician assistants, nurse practitioners, nurses, social workers, community supports, and anyone interested in supporting youth as they transition from adolescent to adult health care.

The Youth Health Transition Initiative, based at the Waisman Center in Madison, facilitates Learning Community activities.

For more information or to sign up to receive notifications of upcoming opportunities visit our Learning Community page.

Provider Education Seminars

In order to meet the needs of individual clinics, we offer the opportunity to customize a presentation format and duration that meets the needs of your practice and health professionals.

For clinic practices just starting their health care transition journey, we recommend starting with a presentation of one, or both, of the following:

Health Care Transition: Basic Overview – Based on tools, resources, and materials created by the Youth Health Transition Initiative. YHTI will present a general overview of Health Care Transition and models. This module is appropriate for health professionals working with adolescents and young adults in a health care setting. It includes a review of transition implementation barriers, consequences, and tools for a medical practice to assess current processes and work towards implementing transition in their clinics.

Getting Started: Implementing Got Transition’s Core Elements – Introduces the survey tools for individual and clinic assessment of health care transition implementation. For teams that have completed the clinic assessment, this time will be used to explore areas of success and identify possible challenges to implementation. We will use this time to review results of the assessment specific to your clinic and provide clinic-wide support, as you implement more of the transition framework into your clinic workflow.

Coming Soon! Supported Decision-Making – This session will define Supported Decision-Making and its role in healthcare. Additionally, it will provide an opportunity for health professionals to understand their role in the use of a Supported Decision -Making agreement, the alternatives to this document, and the exploration of facilitating family decisions and promoting client autonomy.

We continue to develop additional learning modules to meet the needs of health professionals caring for individuals on a health care transition journey.

For information about scheduling a learning opportunity at your clinic or for general information and resources about the providers’ role in transition, contact or Julie Hajewski at

Provider Education Supplemental

American Academy of Pediatrics, American Academy of Family Physicians, & American College of Physicians. (2011). Clinical report—Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics, 142 (5), [update 2018; reaffirmed 2015] – (opens in a new tab)

Annotated Youth Health Transition Resources for Health Care Providers (opens in a new tab)

Got Transition – 2019 Coding and Reimbursement Tip Sheet for Transition from Pediatric to Adult Health Care (September 2017) (opens in a new tab)

Got Transition – Six Core Elements of Health Care Transition 2.0; Side-by-Side Version (opens in a new tab)

Got Transition – Starting a Transition Improvement Process Using the Six Core Elements of Health Care Transition (February 2015) (opens in a new tab)

Health Care Transition Eight Tools (opens in a new tab)

Readiness Assessments (Youth & Family)

Wisconsin Health Transition Initiative Infographic – 2018  (opens in a new tab)

Recommended Journal Articles


Newman, Catherine. How Young People Can Own Their Own Health Care (Even if They Still See a Pediatrician). New York Times. 2020 August 14.


White, Patience H., Cooley, W. CarlTRANSITIONS CLINICAL REPORT AUTHORING GROUPAMERICAN ACADEMY OF PEDIATRICSAMERICAN ACADEMY OF FAMILY PHYSICIANS and AMERICAN COLLEGE OF PHYSICIANS. Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home. Pediatrics. 2018 November.


Benson, R. et al.  A Triple-Aim Approach to Transition from Pediatric to Adult Health Care for Youth with Special Health Care Needs.  Lucile Packard Foundation for Children’s Health. May 2014.

Duncan, RE et al.  Balancing Parental Involvement With Adolescent Friendly Health Care in Teenagers With Diabetes: Are We Getting It Right?  J Adolesc Health. 2014 Feb 8. S1054-139X(13)00782-9.

Gleit, R. et al. Transition Planning:  Teaching Sexual Self-Management.  Contemporary Pediatrics.  April 1, 2014.

Moon, M et al.  Web-Based Education on Primary Care of the Adolescent Patient: Comparison of Internal Medicine and Pediatric Programs Use and Test Scores. J Adolesc Health 2014 Feb 8.  S53.

Sawin, K et al. Transitioning Adolescents and Young Adults with Spina Bifida to Adult Healthcare: Initial Findings from a Model Program.  Rehabil Nurs. 2014 Jan 17.

Suh, E. et al.  General Internists’ Preferences and Knowledge About the Care of Adult Survivors of Childhood Cancer:  A Cross-Sectional Survey.  Ann Intern Med January 2014, Vol 160, No. 1.

Thein-Nissenbaum, JM et al.  Disordered eating, menstrual irregulaties, and musculoskeletal injury in high-school athletes:  a comparison of oral contraceptive pill users and non-users.  Sports Health. 2014 Jul;6(4):313-20.


Annunziato, RA et al. Strangers Headed to a Strange Land? A Pilot Study of Using a Transition Coordinator to Improve Transfer from Pediatric to Adult Services. J Pediatr 2013 August 28.pii: S0022-3476(13)00939-6. doi: 10.1016/j.jpeds.2013.07.031.

Applebaum, MA et al. Perception of Transition Readiness and Preferences for Use of Technology in Transition Programs: Teens’ Ideas for the Future. Int J Adolesc Med Health.  2013;25(2):119-25. doi: 10.1515/ijamh-2013-0019.

Betz. C.L., et al. Voices not heard: A systematic review of adolescents’ and emerging adults’ perspectives of health care transition. Nurs Outlook. 2013 Jul 19 pii: S0029-6554(13)00106-1.

Cerns, S. et al.  Optimizing Adolescent Transition To Adult Care for Sickle Cell Disease.  Medsurg Nurs. 2013 Jul-Aug;22(4):255-7.

Gurvitz, M, et al. Prevalence and Predictors of Gaps in Care Among Adult Congenital Heart Disease Patients: HEART ACHD (The Health, Education, and Access Research Trial). J Amer Coll Cardiol. 2013 May 28;61(21):2180-4. doi: 10.1016/j.jacc.2013.02.048. Epub 2013 Mar 28.

Jan, S. et al.  Association of Hospital and Provider Types on Sickle Cell Disease Outcomes.  Pediatrics. 2013 Oct 28. [Epub ahead of print]

Johnson, HM.  Undiagnosed hypertension among young adults with regular primary care use.  J Hypertens. 2014 Jan;32(1):65-74.

Jordan, L. et al. Systematic Review of Transition from Adolescent to Adult Care in Patients With Sickle Cell Disease. J Pediatr Hematol Oncol. 2013 Apr;35(3):165-9

Lemly, DC et al. Advancing Healthcare Transition in the Medical Home: Tools for Providers, Families, and Adolescents with Special Needs. Curr Opin Ped. 2013 Aug;25(4):439-46. doi: 10.1097/MOP.0b013e3283623d2f.

Lotstein, DS et al. Transition from Pediatric to Adult Care for Youth Diagnosed With Type 1 Diabetes in Adolescence.  Pediatrics.  2013 Apr;131(4):e1062-70. doi: 10.1542/peds.2012-1450. Epub 2013 Mar 25.

Okumura, MJ. Change in Health Status and Access to Care in Young Adults with Special Health Care Needs: Results from the 2007 National Survey of Adult Transition and Health.
J Adolesc Health.  2013 Apr;52(4):413-8. doi: 10.1016/j.jadohealth.2012.08.005. Epub 2012 Oct 28.

Rauen, KK et al. Transitioning Adolescents and Young Adults with a Chronic Health Condition to Adult Health Care: An Exemplar Program.Rehabilitation Nursing. 2013 Mar/Apr. 38(2); 63-72.

Rossignol, L et al.  Empowering Patients Who Have Specific Learning Disabilities.  JAMA.  2013;310(14):1445-1446.

Society of General Internal Medicine. Care Transitions for Young Adults with Special Health Care Needs: Volume 2 SGIM Forum . Apr 2013; 36(4).

Society of General Internal Medicine. Care Transitions for Young Adults with Special Health Care Needs: Volume 1. SGIM Forum. Mar 2013; 36(3)

Tuchman, L., Schwartz, M.  Health Outcomes Associated With Transition from Pediatric to Adult Cystic Fibrosis Care.  Pediatrics. 2013 Oct 21.


White, P.H., et al A Primary Care Quality Improvement Approach to Health Care Transition. Pediatric Annals 2012 (41:5): e1-e7

Bloom, S.R. et al. Health Care Transition for Youth With Special Health Care Needs. J Adolesc Health 2012 Sept; 51(3): 213-9.

Baylor College of Medicine’s Annual Conference: Transition from Pediatric to Adult-based Care

This event is focused on information that will be useful to physicians in internal medicine, family practice, pediatrics, and psychiatry; other health care providers including psychologists, social workers, nurses, dietitians, case managers, counselors, and primary care providers and anyone interested in moving transition efforts forward in their organization.

Each year YHTI shares information about registration and the program for the conference. Details and registration information can be found on our Training & Events page.