Support Adolescent Transitions

“The primary care provider plays an important role to . . . ensure that all young people with special health care needs have an identified health care professional who attends to the unique challenges of transition and assumes responsibility for current health care, care coordination and future health care planning.”

Source: A Consensus Statement on Health Care Transitions for Young Adults with Special Health Care Needs – AAP, AAFP & ACP (2002)


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Site last updated:
July 25, 2014

Wisconsin Resources

Transition Resources - Children's Hospital of Wisconsin (link)

Transition Curriculum & Guidebooks - Waisman Resource Center (link)

Pediatric Pulmonary Center, University of Wisconsin Madison (link)

  • Transition to Adult Healthcare Booklets
  • Electronic Medical Home Care Plan

Southeast Regional Center for CYSHCN

Care Planning Tools

Guardianship Resources - The Arc-Dane County (link)

Wisconsin Statewide Transition Initiative

Wisconsin Healthy & Ready to Work Project

National Resources

Healthy & Ready To Work National Resource Center

University of Washington

The Physician's Guide to Caring for Children with Disabilities and Chronic Conditions: Care Summaries and Plans (link)

Planning for Health Care Transitions: Results from the 2005-2006 National Survey of Children With Special Health Care Needs, Pediatrics. 2009 (link)

Treating Adolescents with HIV: Transitioning Care

Sexuality of Children and Adolescents with Developmental Disabilities, Pediatrics. 2006

Transition to age-appropriate adult health care is a process, not a single event, involving the entire family and the youth’s team. Providers need to address health transitions with families and youth as early as possible, supporting skill building and increased independence as they reach school age, approach adolescence and move into adulthood. Below are some considerations when working with a youth in transition:

  • Anticipate and facilitate the transition to adult health care;
  • Discuss the adolescent's options for health insurance coverage with the family well before age 18 when many adolescents lose their family's coverage;
  • Help families anticipate the need for legal decisions, prior to age18, regarding guardianship, health care power of attorney or other steps to continuity of care;
  • Provide youth and families with information about sexuality to build skills in setting safe boundaries, developing good decision making skills and knowing when to tell a trusted adult about a concern; 
  • Connect families to resources that will assist the young person with the transition to community living.

A physician describes how parents helped guide the development of their transition care plan. A parent and son describe how they’ve approached skill building and responsibility sharing to support his independence and safety.

Medical Home Resources
This section has a wealth of transition care plans to use or adapt, including several condition-specific resources. The state and national Healthy & Ready To Work programs provide resources and training for transition. Wisconsin’s Statewide Transition Initiative Web site offers resource links for every county.