Six Core Elements of Health Care Transition - 3.0 - Transfer of Care - Purpose, Objectives, and Considerations

Sep 16, 2026

The implementation guide defines Transfer of Care as the fifth core element within Six Core Elements of Health Care Transition™ 3.0. It explains why a systematic handoff to an adult clinician is needed to ensure key tasks are completed, youth and families understand the process, and pediatric and adult clinicians coordinate communication and medical information. The guide outlines measurable objectives for completing a transfer package, confirming appointments and responsibilities, preparing and sending transfer letters, and transferring when health conditions are as stable as possible. It also presents information and process considerations for sharing differences between pediatric and adult care and using checklists, packages, and letters.

LanguageEnglish

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Pages11

Reading Time4 min

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Purpose, Objectives, and Considerations

Purpose

Objectives

Considerations

Content

Process

Additional Resources

Six Core Elements of Health Care Transition ™ 3.0 An Implementation Guide Transitioning Youth to an Adult Health Care Clinician Core Element 5 – Transfer of Care I. Purpose, Objectives, and Considerations ............................................. 2 II. Quality Improvement Considerations, Tools, and Measurement........ 4 III. Sample Transfer of Care Tools ........................................................... 9 IV. Additional Resources ....................................................................... 10 © 2020 Got Transition® . Non-commercial use is permitted, but requires attribution to Got Transition for any use, copy, or adaption. Got Transition is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (U1TMC31756) . The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. I. Purpose, Objectives, and Considerations Purpose Transfer of care is the fifth element in the Six Core Elements of Health Care Transition™ (HCT) . Establishing a systematic method for transfer to an adult clinician ensures that key tasks are accomplished; that youth, young adults, and parents/caregivers are informed of and involved in the hand-off of care and current medical information; and that communication and coordination between pediatric and adult clinicians takes place. For youth and young adults with special health care needs, transfer of care often requires coordination among multiple clinicians to ensure a safe and continuous process. Transfer to an adult clinician is recommended before the age of 22. See sample transfer of care checklists and transfer letters in Section III. Objectives Complete transfer package, including final transition readiness assessment, plan of care with transition goals and prioritized actions, medical summary and emergency care plan, and, if needed, legal documents, condition fact sheet, and additional clinical records. Confirm date of first adult clinician appointment. Prepare letter with transfer package, send to adult clinician, and confirm adult clinician’s receipt of transfer package. Communicate with selected adult clinician about pending transfer of care. Confirm the pediatric clinician’s responsibility for care until youth/young adult is seen by an adult clinician. Transfer youth/young adult when their condition is as stable as possible. Considerations CONTENT What information should be shared during the transfer of care? Below are some questions and ideas to think about. • What should be communicated to youth/young adults and parents/caregivers about the differences between pediatric and adult care? (See Got Transition’s System Differences Between Pediatric and Adult Health Care and Planning to Move from Pediatric to Adult Care? Here’s How They Can Differ in Section IV). • Create a checklist of items to include in the transfer package. What will be included in the transfer package for the adult clinician? A transfer checklist can help the practice be sure all the components of the transfer package are done for those youth/young adults leaving the practice (see sample transfer checklists in Section III). • Prepare a transfer of care letter to the adult clinician. o What will be included in the transfer letter to the adult clinician? The amount of medical history detail included depends on if the letter is taking the place of a medical summary. This might happen, for example, if the youth/young adult has had no major medical problems; the letter could include only basic medical information such as immunization and key family history. Six Core Elements of Health Care Transition™ 3.0 An Implementation Guide: Transitioning Youth to an Adult Health Care Clinician Continued on next page 2 o Decide if you will include in the letter the roles of the pediatric clinicians during

FAQs

Why is a systematic transfer of care to an adult clinician recommended before age 22?

It ensures key tasks are completed, youth and families receive information and participate in the handoff, and communication and coordination occur between pediatric and adult clinicians. For youth with special health care needs, it also supports coordination among multiple clinicians.

What are the core objectives of the transfer of care process?

The guide calls for creating a complete transfer package (including readiness assessment, plan of care with goals, medical summary and emergency plan, and required legal/clinical records). It also emphasizes confirming the first adult appointment date, preparing and sending transfer letters, and confirming receipt, plus communicating pending transfer details to the adult clinician.

What information and process considerations should be addressed when implementing transfer of care?

The guide highlights deciding what details to share (including differences between pediatric and adult care), building a transfer checklist, and preparing a transfer letter with appropriate medical history detail and responsibilities during the transition gap. It also recommends developing a standardized process, gathering up-to-date inputs, and coordinating timing, including transferring while insurance is still active when possible.

Sep 16, 2026

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