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Health Care Transition & Title V Care Coordination Initiatives

URL 1:

Date Developed: February-June 2018. Source: Got Transition. Presenter(s): n.a.. Type: Webinar. Level: Intermediate. Length: Series; various lengths.


This is a five-part Webinar Series featuring examples of best practices among state Title V agencies, tools and resources, and problem-solving strategies. Titles include: (1) Starting A Transition Improvement Process Using the Six Core Elements of Health Care Transition; (2) Transition Preparation; (3) Transfer to Adult Care; (4) Integration into Adult Care; and (5) Youth, Young Adult & Parent Engagement. Recordings and handouts are available.

Learning Objectives

Session 1:

• Overview of health care transition baseline results from Title V care coordination (CC) programs.

• Forming a HCT quality improvement team with CC team and youth/young adults/parents.

• Defining HCT pilot population, timeline, measures of success.

• Selecting HCT core elements and delineating roles of CC program and YSHCN providers.

Session 2:

• Identifying key components of HCT policy for CC programs that families/youth want to know.

• Customizing transition readiness assessment (RA) for CC programs

• Piloting and disseminating HCT policy and RA.

• Incorporating RA skill needs into plan of care and educating youth and families on needed skills.

• Preparing medical summary and emergency care plan with youth and families and their providers.

Session 3:

• Identifying willing adult primary and specialty providers.

• Sequencing plans for transferring young adults with multiple providers.

• Identifying ways to support adult practices (consultation, care coordination).

• Preparing transfer package and communicating with pediatric and adult practices.

Session 4:

• Ensuring welcome and orientation FAQs from the adult practice to transferring young adults and pediatric practice.

• Facilitating initial appointment to adult doctor, including confirmation of receipt of transfer package.

• Supporting adult practice with CC assistance from Title V and linking to adult disability resources.

Session 5:

• Identifying youth/young adults/parents to participate in HCT initiatives in Title V CC programs.

• Providing transition education and training and mentoring opportunities.

• Eliciting consumer feedback with HCT care coordination process.

• Building youth/young adult/parent leadership roles on HCT within state Title V programs.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UE8MC25742; MCH Navigator for $225,000/year. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.