Domain 6: Care Transitions

Care transitions are an important part of health care. Those you serve may be experiencing transitions in many ways: youth care transitioning into adult care, transitioning into care facilities and individuals transitioning to different towns or providers. Regardless of the transition, it's important to identify early, discuss often and work together with the individual and their family to prepare and assure integration of services for a successful transition. 

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  1. Support Transitions
  2. Evaluate Services

Support care transitions.

  • Ensure smooth transitions.  Policies and procedures should be in place to ensure smooth, effective transitions between providers, care settings, social service systems and other systems. The policies and procedures should be guided by youth and families, identify roles and responsibilities of all individuals and track utilization of transition support services (see Standard 6.1 for more information).

  • Keep plans patient centered.   The care team should work with families to identify upcoming transitions and any transition related needs. Care coordinators should conduct a readiness assessment (see Standard 6.2 for more information).

  • Share up-to-date records. All updated records (health, education, social, etc.) should be available to families to support transitions (see Standard 6.3 for more information).

  • Plan for the transition. ; The care team should support the transition of care by developing a plan and identifying providers, facilitating warm handoffs and encourage self-efficacy in the patient (see Standard 6.4 for more information).

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