Pediatric practices in the transition program are focused on assisting YSHCN and their families to get ready for “graduation” out of pediatrics and into adult-based primary care. The care coordinators and other team members at the pediatric medical home will talk with the youth and their family beginning at age 14 to ascertain what concerns they have as they approach the age of 18-21 with regard to planning for ongoing services.
Additionally, a practice with the family to assess strengths and areas for growth as the youth moves closer towards this graduation. Care coordinators will work with the family to develop a transition care plan and connect with any resources the youth and their family may need to support their graduation on to a more adult oriented system of medical care. The purpose of this planning and preparation is to create a smoother path to this adult oriented system so needed supports and services are not disrupted.
The PA Medical Home Team works closely with each of these practices to implement tools to assist in readiness assessment, identify good quality resources for the practices and their families, meet face to face regularly to review progress of the transition team at each practice and identify and recruit primary care practices who serve adults to partner with them to receive graduating YSCHN.