Six Core Elements of Health Care Transition - 3.0 - Transition Planning Implementation Guide - Core Element 4

Sep 12, 2026

A practical implementation guide for Core Element 4, Transition Planning, within the Six Core Elements of Health Care Transition 3.0 framework. It outlines the purpose and measurable objectives for developing and regularly updating a plan of care with youth and families, building health literacy and independent self-care, addressing legal considerations related to supported decision-making, and coordinating timing for transfer from pediatric to adult care. The guide also emphasizes cultural preferences, decision-making supports, consent for releasing medical information, and links to adult clinician selection and community resources, supported by planning tools and measurement approaches.

LanguageEnglish

CategoryPresentations

FormatPDF

Pages12

Reading Time4 min

AccessFree to download

Purpose, Objectives, and Considerations

Purpose

Objectives

Considerations

Quality Improvement Considerations, Tools, and Measurement

Sample Transition Planning Tools

Additional Resources

Six Core Elements of Health Care Transition ™ 3.0 An Implementation Guide Transitioning Youth to an Adult Health Care Clinician Core Element 4-Transition Planning I. Purpose, Objectives, and Considerations ............................................. 2 II. Quality Improvement Considerations, Tools, and Measurement........ 5 III. Sample Transition Planning Tools .................................................... 10 IV. Additional Resources ....................................................................... 11 © 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 Transition planning is the fourth element in the Six Core Elements of Health Care Transition™ (HCT) . Planning for transition should be accomplished in collaboration with youth and parents/caregivers beginning in early adolescence and continuing until the youth transfers out of pediatric care. Transition planning encompasses several ongoing activities that are intended to build health literacy and independent self-care skills; assist in preparing for changes that happen at age 18; and guide the timing of transfer and the selection of a new adult clinician, taking cultural preferences into account. In addition, addressing the legal issues of supported decision-making should be a part of this planning, if needed. See sample transition plans of care and medical summary and emergency care plans in Section III. Objectives Develop and regularly update the plan of care, including readiness assessment findings, youth’s goals and prioritized actions, medical summary and emergency care plan, and, if needed, a condition fact sheet and legal documents. Prepare youth and parent/caregiver for an adult approach to care, including legal changes in decisionmaking and privacy and consent, self-advocacy, and access to information. Determine need for decision-making supports for youth and make referrals to legal resources. Plan with youth and parent/caregiver for optimal timing of transfer from pediatric to adult care. If both primary and subspecialty care are involved, discuss optimal timing for each. Assist youth in identifying an adult clinician(s) and provide linkages to insurance resources, self-care management information, and community support services. Obtain consent from youth/parent/caregiver for release of medical information. Take cultural preferences into account throughout transition planning. Considerations CONTENT What information should be considered in developing a plan of care for transition? Below are some questions and ideas to think about. • Does the practice already have a plan of care template and/or an HCTplan of care template? If the practice has a transition plan of care template, does it encompass some or all ofthe objectives listed above? • At what age will the plan of care for transition be developed with youth and parents/caregivers and how often will it be updated? What issues should be considered in creating a medical summary and emergency care plan that is shared with youth and parents/caregivers? Below are some questions and ideas to think about. • Does the practice have a medical summary template in its emergency medical records (EMR) ora way to create a medical summary within its EMR? • Does the practice have an emergency care plan template available, or will the practice use another available template? (See Got Transition’s template or those created by the American College of Physicians Subspecialty Society in Section III.) • What is the key information

FAQs

What is the main purpose of transition planning in the Core Element 4 framework?

Transition planning is designed to be carried out with youth and parents/caregivers starting in early adolescence and continuing until the youth leaves pediatric care. It builds health literacy and independent self-care skills, supports preparation for changes at age 18, and guides transfer timing and selection of a new adult clinician with cultural preferences in mind.

Which objectives should be included in a comprehensive plan of care for transition?

The plan should be developed and regularly updated, including readiness assessment findings, youth goals and prioritized actions, a medical summary and emergency care plan, and—if needed—a condition fact sheet and legal documents. It should also prepare families for adult care approaches, decisionmaking support needs, and optimal transfer timing.

What considerations are highlighted for a medical summary and emergency care plan shared with youth and parents/caregivers?

The guide prompts practices to have templates in the EMR or a way to create a medical summary, and to use an emergency care plan template as available. It specifies that key information must be included and notes that non-medical strengths can help new adult clinicians connect during early visits.

Sep 12, 2026

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