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Curr Opin Pediatr. 2013 Aug;25(4):439-46. doi: 10.1097/MOP.0b013e3283623d2f.

Advancing healthcare transitions in the medical home: tools for providers, families and adolescents with special healthcare needs.

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Division of Adolescent Medicine/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts 20115, USA.



The purpose of the present article is to review recent national guidelines regarding healthcare transition (HCT) planning for adolescents with special healthcare needs (SHCN) and to describe practical tools for use by the primary care pediatrician to implement these guidelines.


Approximately one in five adolescents in the United States has SHCN. Achieving successful transitions from child-oriented to adult-oriented healthcare for these patients can be difficult. Despite numerous barriers to HCT, innovations in healthcare delivery, including the patient-centered medical home and accountable care payment structures, may help overcome challenges. The American Academy of Pediatrics, American Academy of Family Physicians, and the American College of Physicians have provided explicit practice-level guidance for supporting HCT. The National Healthcare Transition Center developed the Six Core Elements of Healthcare Transition, recommending six detailed action steps for transitions from pediatric settings. Steps reflect guidelines and, along with novel patient-centered information technologies, may help support individuals and families navigating complex transitions.


It is time to integrate transition planning into the medical home. Further evidence is needed to identify transition strategies that improve outcomes. Although innovations in care delivery, payment structures, and information technologies may support HCT, pediatricians can and should implement already available and recommended transition steps.

[Indexed for MEDLINE]

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