Transitions by Age

Transitioning your child to the adult health care system requires a lot of information and consideration based on their age. The following will provide a starting point as you begin this process.

12-14 years old

It’s not too early to start thinking about transition at 12-14 years old. The patient may start relying less on the parent/guardian and having more one-on-one time with the medical team. The patient is more involved in decision making in all areas of life, including school, medical, and financial. This is based on the patient’s abilities and understanding.

At this stage, discussions about transition to adult care with the parent/guardian and the patient include the following:

  • Complete the readiness assessment.
  • Understand the extent parents may have to remain involved in managing the care of the patient.
  • Learn how the transition will occur in different settings (school, insurance, medical system, etc.).
  • Understand transition services and the transition process in regard to the patient continuing care in the CHOSeN Transition Program.

A social worker will follow up on transition processes continuously until completed. The patient should be seen in the CHOSeN Transition Program with Holly Volek-Smith, MD, for the first time around age 15. The parent/guardian and the patient are encouraged to start preparing for the physician change. They can contact the social worker at any time with questions or concerns regarding the transition.

15-17 years old

At this stage, the patient is able to participate more in their health care, such as make appointments, manage medications, and keep up with the care plan, emergency plan, and medical summary.

Discussions about transition to the adult health care system with the parent/guardian and the patient include the following:

  • Review and complete the transition tool.
  • Discuss SSI and changes with insurance, waiver programs, and other benefits.
  • Understand the adult model of care and important timelines/time frames when the patient turns 18 and will legally be an adult.
  • Learn referral options for primary (PCP) and specialty care physicians, as well as discuss with current providers.
  • Determine the high school graduation plan (e.g., higher education, dayhab) and community involvement.
  • Understand privacy and consent laws, as well as have legal documents, when warranted.
  • Follow up on the permanency plan.
  • Complete Guardianship/Power of Attorney (POA)/Supportive Decision Making. Parents are encouraged to begin these processes of obtaining Guardianship/POA/Supportive Decision Making when their child is 17 ½ years old.

A transition packet will be discussed in detail, and the family should receive a copy. They are encouraged to begin reading it and documenting questions for upcoming visits and future transition discussions. The parent/guardian and the patient are encouraged to review, complete, and finalize the transition tool before age 17.

18-21 years old

At this stage, discussions about transition to the adult health care system with the parent/guardian and the patient include the following:

  • Determine the high school graduation plan, (e.g., higher education, dayhab) and community involvement.
  • Review transition tool, portable medical summary, permanency plan, and emergency information form (EIF).
  • Create privacy and confidentiality protection (release of record or other legal documents should be on file).
  • Complete or maintain Guardianship/Power of Attorney (POA)/Supportive Decision-Making process.
  • Learn specifics of insurance programs (pediatric insurance benefits verses adult benefits).
  • Understand SSI and changes with insurance, waiver programs, and other eligible benefits.
  • Determine equipment and supplies needed for long-term care.
  • Receive referral options for primary care physician and specialty care physicians (should discuss with current providers).
  • Transfer medical records and update medication/diagnoses lists.

Parent/guardian and the patient will be provided with a transition packet with a list of specialists and dentists who accept patients with multiple and chronic conditions. If the needed providers aren’t listed, or the parent/guardian or patient prefers other options, they will need to begin contacting an insurance/service coordinator or case worker about available providers within the insurance plan’s network.

A copy of the portable medical summary should be given to the family before age 18. The goal is to have a useable summary prior to transition from the CHOSeN Transition Program.

22-25 years old

In this final stage, discussions with parent/guardian and patient about finalizing transition to the adult health care system include the following:

  • Review transition readiness.
  • Update medication/diagnoses lists.
  • Review and update Guardianship/POA/Supportive Decision-Making documents.
  • Discuss SSI and changes with insurance, waiver programs, and other eligible benefits.
  • Review current adult specialists versus pediatric specialists. You can request permission to continue care with the pediatric specialist for continuity of care if adult providers have not been identified.
  • Review transition tool, portable medical summary, permanency plan, and emergency information form (EIF).
  • Ensure release of records form is on file to request records be transferred to all new doctors (dental, PCP, specialists).
  • Receive transfer letter and/or packet.
  • Provide referrals and schedule first appointments with new PCP, dentist, and adult specialists.

Parent/guardian and the patient will be provided with a portable medical summary as well as transition packet. The transition packet has a list of PCPs, specialists, and dentists who accept patients with multiple and chronic diagnoses. If providers needed are not listed, or parent/guardian or patient prefers other options, they will need to begin contacting insurance/service coordinator or case worker about available providers within the insurance plan’s network.