Got Transition: Bringing Health Care Transition to Your Practice

Tenesha Wallace, MA (Manager of Communications and Public Health, GAFP)

18 million U.S. adolescents, ages 18–21, are moving into adulthood and will need to transition from pediatric to adult-centered health care. According to the 2009-2010 National Survey of Children with Special Health Care Needs, only 40% of youth with special health needs are receiving needed transition preparation. Although most providers are encouraging youth with special needs to assume responsibility for their own health, far fewer are discussing transfer to an adult provider and insurance continuity.

Improving transition from pediatric to adult health care is a national priority, a medical home standard, and a meaningful use requirement for electronic health records.  Got Transition aims to improve transition from pediatric to adult health care through the use of new and innovative strategies, clinical recommenations, and transition tools for health professionals, youth and families. The goals in supporting transitions include supporting adolescents in understanding their health care needs and how to manage them, advocating for themselves and communicating their health care needs and realizing their goals in ongoing education, career and personal life.  To achieve this goal requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in care.

Got Transition has updated the clinical resources on transition from pediatric to adult health care.  The Six Core Elements of Health Care Transition 2.0 defines the basic components of transition support.  These core elements are consistent with 2011’s “Clinical Report on Health Care Transition,” which was jointly developed by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians for use by Pediatrics, Family Physicians and Med-Peds Providers.  The Six Core Elements of Health Care Transition includes the following steps:

  1. Transition Policy: Discuss Transition Policy
  2. Transition Tracking and Monitoring: Track Progress
  3. Transition Readiness: Assess Skills
  4. Transition Planning: Develop Transition Plan
  5. Transfer of Care: Transfer documents
  6. Transition Completion: Confirm completion

Janice Nodvin, Executive Director at the Adult Disability Medical Home (ADMH), started using the Got Transition “Transition Readiness” tool and found it to be supportive with their families. ADMH is a comprehensive medical practice for teens and adults with Down syndrome and other developmental disabilities. ADMH revamped their readiness assessment tool and received feedback from families such as, “the tool helps us think about our young adult’s future medical needs.”  In addition, Janice found that helping families setup an Emergency Plan and repeatedly verbalizing the message helps families to move from planning to preparation.

The American Academy of Pediatrics has just released a 2017 Transition Coding and Reimbursement Tip Sheet to support the delivery of health care transition services in pediatric and adult primary specialty care settings.

The tip sheet includes:

  • An updated list of transition-related CPT codes (including the new code for transition readiness assessment) with current Medicare fees and relative value units (RVUs).
  • Seven clinical vignettes with recommended CPT and ICD-10 codes.
  • Detailed CPT coding descriptions for transition-related services with selected coding tips.

Health Care Transition Resources for Georgia Providers:

Contact Information

Georgia Department of Public Health

Children and Youth with Special Health Care Needs (CYSHCN)

2 Peachtree Street NW

Atlanta, GA 30303