Supporting Youth to Adult Health Care Transition

Health Care Providers

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.

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Shared Plan of Care 2020 Quality Improvement Grant Opportunity

Advancing Family-Centered Care Coordination for Children and Youth with Special Health Care Needs 2020 Shared Plan of Care Quality Improvement Grant Project Opportunity now available. Go to our Quality Improvement Grants page for an overview, grant guidance and information on grant submission.

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).

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 each of the individual clinics, we offer several presentations formats. The duration of the presentation varies, but typically runs over a one hour lunch allowing for 45 minutes of content, and 15 minutes for questions and wrap up. Each module taking approximately 12-15 minutes, but this depends on each clinic.

Consider your audience when choosing your topics (i.e. Med/Peds, Peds only, Internal Med, Specialty only, or other?)

We offer 6 topic foci; if this will be the first time many of your staff will be hearing about this our A or B option, or hybrid is the best choice.

Each topic is addressed in 12-15 min.

Topic A: Health Care Transition: Basic Overview – based on tools, resources, and materials created by Health Transition Team, the YHTI will present a general overview of Health Care Transition and models. Appropriate for any health care provider working with adolescents in a health care setting including broad suggestions for strategies to use in interacting with adolescents and their families and navigating the transition process.

Topic B: Getting Started: Implementing Got Transition’s Core Elements – for teams that have completed the clinic assessment provides us with a good idea of the areas your clinic is successful and areas that might pose challenges. We would use this time to review those specific to your clinic and provide clinic-wide support as you implement more of the transition framework into your clinic workflow.

The other topic areas:

C: Understanding Childhood-onset conditions (one condition/session)
D: Engaging Individuals and Families in Transition – might be another option; but would require most of team to be familiar with Got Transition and your grant work
E: Implementing Shared/Supported Decision Making
F: Applying the Person-Centered Approach with Adults with Disabilities

If you are interested in scheduling a learning opportunity at your clinic, contact us 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


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 2020

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.

The conference will be October 29 and 30, 2020 and will be streamed live in Madison and Milwaukee, WI. Details can be found on our Training & Events page closer to the conference.