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Healthcare Transition: Current Recommendations and their Application

October 3, 2012

Patience White, MD, MAVice President, Public HealthArthritis FoundationProfessor of Pediatrics and MedicineGeorge Washington UniversitySchool of Medicine and Health Sciences

Faculty Disclosure Information

• In the past 12 months, I have had no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

• I do not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation.

Opening Questions About Your Transition

• What do you remember about your adolescent/young adult years and health care-when did you leave your pediatrician and move to an adult health care provider?

• Was your health care continuous or was there a gap?

• Did you leave actively (plan your transfer to an adult HCP) or passively?

Learning Objectives

• Define health care transition and related data from those involved in HCT

• List the key elements of the AAP/ACP/AAFP clinical report on practice-based implementation of transition planning for all youth beginning in early adolescence.

• Discuss DC Learning Collaborative process and outcome• Identify opportunities within one's own practice for

improvement in the transition of youth from pediatric to adult medical care

Who Are CYSHCN?

“ Children and youth with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”

Source: McPherson, M., et al. (1998). A New Definition of Children with Special Health Care Needs. Pediatrics. 102 (1); 137-139.

What is a Medical Home?

• The American Academy of Pediatrics (AAP) definition:

• Primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective

• Not a building, house, or hospital, but an approach to providing comprehensive care

Source: McPherson, M., et al. (1998). A New Definition of Children with Special Health Care Needs. Pediatrics. 102 (1); 137-139.

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Prevalence of CSHCN NY US

CSHCN Prevalence

Percent of children who have special health care needs

15.0% 15.1%

CSHCN Prevalence by Age

Age 12-17 years 17.9 18.4

CSHCN Prevalence by Sex

Male 17.2 17.4

Female 12.5 12.7

CSHCN Prevalence by Poverty Level

0-99% FPL 16.7 16.0

100-199% FPL 14.8 15.4

200-399% FPL 13.5 14.5

400% FPL or more 14.8 14.7

NY US

CSHCN Prevalence by Hispanic Origin and Race

Non-Hispanic 15.3 16.2

White 15.5 16.3

Black 17.2 17.5

Other 10.5 13.6

Hispanic 13.2 11.2

Spanish Language Household 19.7 8.2

English Language Household 7.4 14.4

Prevalence of CSHCN: NY vs. US

Prevalence U.S. (%)Proportion of Youth with Special Health Care Needs, Ages 12-17

18%(4,581,950)

Proportion of YSHCN with functional limitations 24

Proportion of YSHCN with 2 or more chronic conditions 62

Proportion of YSHCN with emotional, behavioral, or developmental conditions

64

Source: National Survey of Children with Special health Care Needs, 2009/10

How Many Youth Need Transition Services?

What is Health Care Transition?Transition is the deliberate process of moving seamlessly from child-oriented health care to adult-oriented health care.

Components:• Self-Determination• Person-Centered Planning• Prep for Adult Health Care• Work/Independence • Inclusion in Community Life • Start Early

The Transition Process

Transfer of Care

Pediatric Care Adult Care

Transition

SOURCE: Rosen DS. Grand Rounds: all grown up and nowhere to go: transition from pediatric to adult health care for adolescents with chronic conditions.

Presented at: Children’s Hospital of Philadelphia; 2003; Philadelphia, PA

Start Early-How Early?

• Data from studies in Europe and the US suggest age to start transition process is

11-13:

– Youth with SHCN 12-13 yrs: most interested in involvement with future career like their peer group without SHCN

– For YSHCN < 14yrs: there is less of a gap in standardized QoL and life skills measures and show more improvement with transition intervention services than those > 14yrs

– Bottom line: • Transition planning starting at ages 12-13 enabled CYSHCN to stay

on developmental milestones as they grew up compared to those starting transition planning later

WHAT DO DATA TELL US?

What do youth say they want in transition?

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Youth are less interested in any transition organized around

medical issues andmore interested in a

transition to financial and social independence.

THE FUTURE JOB MARKET How to be prepared:

• Get as much education as possible• Keep upgrading your skills-retrain• Sharpen career exploration/development

skills to keep up with fast changing technology and global economy

• Expect to change careers - not just jobs -three or four times during the working years

-US Dept. of Labor

Data on Adolescent Work in the USA• Employers rank prior work experience, attitude and

communication skills most important in hiring decisions

• Work patterns of teenagers during the school year:- 40% 7th and 8th graders - 80% high school students

• Parents underestimate youth work hours• Educational level attained relates to survival, future

income level and probability of labor force participation

Post-Secondary Education Issues

• Selection of school: College visits and/or Career training with support services

• Medical supports needed at school, visit to campus (where is the health unit?) and the DDS office, campus size, and plans for local rheumatology care and emergency care.

• Insurance Coverage (is it adequate and is it one plan or a patch of plans)

• Modifications: Work Load, Housing, medications

FACTORS ASSOCIATED WITH RESILIENCE for youth with disabilities: Which is MOST important?

Self-perception as not “handicapped”

Involvement with household chores

Having a network of friends

Having non-disabled and disabled friends

Family and peer support

Parental support w/out over protectiveness

Source: Weiner, 1992

WHAT DO DATA TELL US?

What proportion of parents report receiving adequate transition support for their YSHCN?

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Proportion of Youth with Special Needs Who Receive Services

Needed to Make Transition to Adult Health Care

U.S. (%)Total YSHCN meeting transition measure

40%(1,708,799)

GenderMale 37Female 44

Race/EthnicityBlack 28White 46Hispanic 25

InsurancePrivate insurance only 50Public insurance only 26Uninsured 20

Presence of a medical homeWith a medical home 55Without a medical home 29

NA = sample size too small for reliable estimates.

Source: NS-CSHCN 2009/2010

Adolescents Meeting Transition Outcomes: NY and US

Performance on Core Transfer Outcomes NY US

Overall Performance 40% 40%

Gender

MaleFemale

3743

3744

Medical Home

With Without

6324

5529

WHAT DO DATA TELL US?

How prepared are youth for managing their care in the adult health care system?

Internal Medicine Nephrologists (n=35)Survey Components Percentages

Percent of transitioned patients < 2% in 95% of practices

Transitioned patients came with an introduction 75%Transitioned patients know their meds 45%Transitioned patients know their disease 30%Transitioned patients ask questions 20%Parents of transitioned patients ask questions 69%Transitioned adults believed they had a difficult transition 40%

Source: Maria Ferris, MD, PhD, MPH, UNC Kidney Center 2011

Prepare for the Realities of Culturally Different Pediatric and Adult Health Care Services

• Pediatric Services: Family Driven

• Adult Services: Consumer Driven

The youth and family finds themselves between two medical worlds

…….that often do not communicate….

Difference Between Systems

Pediatric Adult

Age-related Growth, development and future focused

Maintenance/decline; optimize the present

Focus Family IndividualApproach Proactive, paternalistic Reactive, collaborative

Shared decision-making With family/parent With patient who is a self-advocate

Insurance/services Entitlement Qualify/eligible

Non-adherence More assistance More tolerance

Procedural Pain Lower threshold Higher threshold # of patients Fewer Greater

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What do pediatric and adult physicians say they do and need to assist YSHCN?

WHAT DO DATA TELL US?

AAP Periodic Survey #71 2008 Results*

• 47% assisted with a referral to family or internal medicine• 45% Refer to adult specialists• 33% discussed consent and confidentially issues prior to

age 18• 32% Assist with finding a medical doctor• 27% Create a portable medical record summary• 23% offered education and consultative support to families

or adult providers• 19% assisted in identifying insurance options after age 18• 12% create an individualized health care transition plan

* For all or most of their adolescents

Barriers to transition care for Pediatricians (both major and minor barriers combined):

• 88% lack of their knowledge of community resources • 85% fragmentation of adult health care • 84% lack of adolescent knowledge about their health

condition and skills to self advocate during health care visits

• 80% lack of adult primary care and specialty providers, • 80% difficulty breaking bond with adolescents and

parents • 79% lack of office staff skills in transition • 76 % lack of reimbursement for transition activities

2008 AAP Periodic Survey# 71

Areas to Consider to Bridge the HCT Gap: Provider Needs/Activities

Adult HCP Pediatric HCP • 95% want initial and ongoing communication

with previous providers• 100% request a medical history (written

summary) and disease info

• 47% assist youth with referral to adult physician • 27% create portable medical record• 23% offer consultative support to family or

internal medicine physicians• 80% find it difficult to break the bond with

youth/family

• Youth ready to make independent health decisions

• Disease management skills (know disease/meds/make appt/refill prescriptions, etc.)

• Youth guardianship issues clarified

• 84% of youth lack knowledge about condition• 33% of pediatricians discuss consent and

confidentially issues before 18• 12% of pediatricians create Individual transition

plan

• Medical home • Financing (insurance), infrastructure• Increase medical knowledge of pediatric

diseases• More adult providers (gen and sub)

• Medical home • Financing (insurance), infrastructure• Assist in medical knowledge of adult providers• More adult providers (gen and sub)

Source: DC Provider Survey, AAP Periodic Survey, Annals Int Med Adult Provider Survey

What to do? Where to start?

General Assumption #1

•

• Every youth deserves a continuous medical home as they

grow into adulthood utilizing a transition plan that

matches:

– the youth’s capacity for independent decision making (both well and crisis care)

– the complexity and course of the medical condition(s) – and capacity of family and a circle of support

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Health Care Transition ServicesIn the past and currently…• Medical transition services provided by:

– patchwork of pediatric clinics mostly in university subspecialty setting – less common to have transition services in primary care setting– Med-Peds physicians seen as logical providers of transition care services but few

available

• National data reveal little progress made in transition from pediatric to adult health care in last decade despite a 2002 Consensus statement by AAP/ACP/AAFP including identifying core transition knowledge and skills and recommending transition plans

• Literature reviews reveal inconclusive evidence regarding role of transition programs to facilitate transition. Only evidence for improved outcomes suggests meeting adult providers before transfer improves post transfer access and quality of care (Bloom 2012)

• Surveys of pediatricians, family physicians and internists point out the need for more information and support re: transition

New Health Care Transition Clinical Reportbackground

• 2 years ago, AAP/ACP/AAFP appointed a Transition Authoring Group to develop a clinical report based on data and clinical practice

• Clinical Report: Provides practical, detailed guidance (including a step-by-

step algorithm) on how to plan and implement better health care transitions for all patients

Integrates transition planning into the medical home and ongoing chronic care management

Provides guidance for financial support of HCT• Publication: “Supporting the Health Care Transition from

Adolescence to Adulthood in the Medical Home” (Pediatrics, July 2011) – clinical report jointly authored by the AAP, the AAFP, and the ACP

Health Care Transition Clinical Report

• Targets all youth, beginning at age 12 and links the process to the medical home

• Algorithmic structure provides logical frameworkBranching for youth with special health care needsApplication for primary and specialty practices serving

children and adults with variety of conditions Structure for training, continuing education, & research

• Provides explicit practice-based guidance for planning, decision making, and documentation processes

• Extends through the transfer of care to an adult medical home and adult specialists

Health Care Transition Milestones(transition visits from the algorithm)

• Age 12 – Youth and family aware of the practice’s health care transition and transfer policy

• Age 14 – Health care transition planning initiated

• Age 16 – Discussion of youth and parental expectations and preferences regarding adult health care

• Age 18 – Transition to adult model of care even if remain in a pediatric setting before moving to adult model of care (appropriate guardianship issues addressed for cognitive ability)

• Age 18-22 – Transfer of care to adult medical home and specialists with privacy policies and self management skills assessments

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National Health Care Transition Center • MCHB-funded resource center, GotTransition.org

• Responsible for developing transition tools aligned with clinical report and fostering practice changes

• Use of Learning Collaborative (LC) methodology used by the National Initiative for Children’s Healthcare Quality (NICHQ) and pioneered by the Institute for Healthcare Improvement (IHI). Primary care expert panel in DC led the way developing

o LC charter oThe 6 core HCT elements based on the algorithm oTransition tools oHCT index for evaluation

LCs in DC, Denver, Boston, NH

For more information: www.GotTransition.org

Methodology: Evidence for Learning Collaboratives

• Learning collaboratives (LCs) – Shown to improve several aspects of pediatric care – Effective method of improving the quality of care delivered by pediatric

practices

• Collaborative teams have achieved dramatic results, including:– Reducing wait times by 50%– Reducing worker absenteeism by 25%– Reducing ICU costs by 25%– Reducing hospitalizations for patients with CHF by 50%

Transition Intervention: 6 Core Elements For Practice Transformation

Pediatric Health Adult Health

1. Transition Policy 1. Privacy and Consent Policy

2. Transitioning Youth Registry 2. Young Adult Patient Registry

3. Transition Preparation 3. Transition Preparation

4. Transition Planning 4. Transition Planning

5. Transition and Transfer of Care 5. Transition and Transfer of Care

6. Transition Completion 6. Transition Completion

Designing a LC for Health Care Transition

• Unique featuresDyads of pediatric and adult practices Involvement of care coordinatorsConsumer involvementWorking across organizations and

systems to improve care throughquality improvement project

• Design and timelinesTeaching and learning strategies Incorporate elements to fit each

practice’s processesPractice, accountability, shared learning

DC as a National Transition Model: Learning Collaborative Teams

Howard University Hospital Team

Children’s National

Medical Center Team

Georgetown University Hospital Team

George Washington University Medical Center TeamCNMC Children’s Health Center -

Adam’s Morgan Team

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Goal of Learning Collaboratives:incorporate the 6 core elements into their practice processes

• Develop a written health care transition (privacy and consent) policyfor families, patients, and staff

• Develop a transition registry to know which patients are in the process and tracking major steps in their progress

• Test and use transition preparation and planning tools Portable medical summary Readiness assessments Healthcare transition plans Chronic condition fact sheets Transfer checklists

• Utilize an adult model of care at 18 yrs (if cognitively appropriate)

• Transfer prepared youth/young adults to adult medical homes

FIRST STEP in The HCT Transition QI Process

• Do you have a transition Policy for your practice?A transition policy is an explicit office policy describing thepractice’s approach to health care transition, including the ageand process at which youth shift to an adult model of care(pediatric) or describing the practice’s privacy and consent policy(adult).

• If yes, do you post it for parents and youth to see and give it to all new patients in your practice?

How do we create a systems change so that the rookie learns the rules of the game and we leave no knot untied between pediatric

and adult healthcare?

• Research states policies and procedures among stakeholders are essential– Ensures consensus– Ensures mutual understanding of

the processes involved– Provides structure for evaluation

and audit

Transition Policy Template

• Definition-what is it? See transition definition of Soc

Adolescent Med/BMCH

• Outcome- when the youth has left my practice, he/she should know/have…..

• Timeline- age of initiation and explanation of exceptions

• Components- see AAP consensus statement

• Practice Processes• Evaluation- PDSA cycle

Adolescent Clinic Transition Policy

The Adolescent Health Center is committed to helping all of our patients make a smooth transition from pediatric to adult health care.

This process requires working with you to plan and prepare your transition starting around your 14th birthday.

According to hospital policy, all patients are expected to transition from CNMC to an adult primary care medical home by age 22 years.

We will provide you with ongoing resources to help you to take increasing responsibility for your own health care to the best of your abilities.

We are also able to help you select a medical provider that participates with your insurance, to organize your medical records, and to support all other aspects of planning for this important transition as part of lifelong preparation for a successful and well adult life.

Transition Policy• Challenges

– Getting practice/team consensus, especially regarding age limits– Posting and having policy distributed systematically– Difficulties when consent, privacy, and guardianship issues have not been

discussed prior to age 18. Many parents unaware of HIPAA requirements and want to be present during visit.

– Assessing patient’s decision-making ability

• Benefits– Patient Satisfaction-Families who reviewed the pilot policy said they were

grateful for the information. Many wished they’d had it when their older children were transitioning

– Provider Satisfaction-practice consistency– Clarifies roles of youth/young adults and parents in decision-making– Creates a safe and comfortable environment for those 18 and over to discuss

private concerns regarding their health– Improved adherence and outcomes

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Types of Decision Making Support• Informal Supports – Family, friends, and “circle of support” • Money Management – Joint or trust accounts, direct deposit,

direct payment, Social Security representative payee, financial power of attorney, conservator

• Health Care - Health-Care Decisions Act, Durable Power of Attorney for Health Care

• Temporary/Limited / full Guardianship-The specific type of guardianship is defined in the applicable laws for each state/jurisdiction.

• References:– Guardianship webinar available at

http://www.gottransition.org/about-us-news/broadcasts – dcqualitytrust.org: Quality Trust for Individuals with Disabilities

Health & Wellness-The Basics:Yes I do this

I wantto do this

I need To learn

Someone else will have to do this - Who?/NA

1. I understand my health care needs and my chronic illness/disability 2. I can explain my illness, medications and health care needs to others3. I have a list/ can explain my medications and their side effects to others4. I carry my health insurance card everyday

5. I know and pay attention to my baseline health and wellness

6. I track and schedule my own medical appointments

7. I know when to call my provider for prescription refills 8. I know how to call the pharmacy for my refills

9. Before an appointment I prepare written questions to ask or list any concerns I have10. I know what to do when my condition

changes such as when to call my doctor

11. I know what to do in an emergency and have ICE information in my cell phone

Transition Readiness Assessment- For Youth/Young Adults

Transition Readiness Assessment: Challenges

• Addressing range of patient education levels into youth and parent assessment that can be used by entire practice

• Identifying practice process for how all youth/young adults and parents receive and fill out assessment

• How to incorporate readiness assessment into transition plan and into visit discussions/follow-up

• How to incorporate readiness assessment into EMR so it can be updated

• Have available updated readiness assessment for transfer packet for adult provider

• Time constraints

Transition Readiness Assessment: Benefits

• Solicits greater involvement of patients/families in understanding their ability to manage their own health and health care

• Evaluate youth and young adults’ current healthcare knowledge base and skills and identify areas that need further education

• Ultimately, improves the management of chronic condition and the independence of youth/young adults in their own care

What is Your Changing Role in the Transition Process?

Shared Management Model to changing roles

Provider Parent/Family Young Person

Major responsibility

Provides care Receives care

Support to parent/family and child/youth

Manages Participates

Consultant Supervisor Manager

Resource Consultant Supervisor

Portable Medical Summary • Components of portable medical summary

Basic patient personal and contact information Build Health Family Tree https://familyhistory.hhs.gov/ Medical providers, emergency contacts Diagnosis Pertinent history Current medications, equipment needs Allergies Immunizations Special notes — guardianship status, communication preferences Prevention Actions– General: nutrition, physical activity guidelines, routine screenings, tests

according to age– Specific actions/screenings required due to the family health tree eg heart

disease• Portable and electronic and share with young adult/family (before age 18) &

providers• Developed with institution’s HIT team to generate from EMR

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Portable Medical Summary: Benefits

• Improves understanding and self-care management

• Prevents duplication of tests/procedures

• Youth/young adults/parents don’t have to repeatinformation to multiple providers

• Improves patient safety

• Ensures adult providers have accurate information

Discuss the Process to find the “Right” Adult Provider for Your youth/young adult

• Prepare a list of desired qualities• Prepare a list of questions• Solicit recommendations from provider/family-friend

network• Check out the internet• Call the adult office to ask how the process works

(attitude, convenience, appointments, cost/insurance, reaching the doctor, hospital, etc.)

• Appointment for an “interview”?

Health Care Transition Transfer of Care Checklist

<Patient Name> <Date of Birth> Date Transfer of care policy discussed with youth and family

Transfer of care options discussed with youth and family

Pediatric primary care practice confirms transfer with adult primary care practice

Final youth readiness assessment completed

Transfer of care package prepared or updated (for all youth, for YSHCN) includingportable medical summary, readiness assessment, emergency care plan, transition planand medical condition fact sheets

Transfer of care packagecommunicated to adult primary care provider via best available means (mail, fax, email, electronic health information transfer)

Initial visit with new adult primary care provider scheduled

Follow-up communication with emerging adult (and family as appropriate)by pediatric primary care team regarding completion of transfer of care and level of satisfaction with result

Follow-up communication with new adult primary care team by pediatric primary care team regarding completion of transfer of care and level of satisfaction with results; identify any future plans/needs for on-going communication or consultation

Risk Stratification/Complexity Score for Practice Communication Strategy

CSHCN Complexity Rating Description Examples Practice Communication Strategy

Low(1 point)

Chronic conditions well-controlled OR

Significant past medical history, quiescent or

resolved

Asthma, mild per.

Repaired ventricular septaldefect

Email

Moderate(2 points)

2 or more chronic conditions, with either

unstable

AsthmaGERD

Asthma with ER visitType 2 diabetes mellitus

Asthma + ADHD

Call between MDs

Complex(3 points)

Any tech. dependent patients

Moderate/ severe cognitive delays

(wheelchair, walker, GT, Trach)

MR, autism, group home respirator

Call between MDs and care coordinators

(+1 point) Language barrier Non-English Speaker(+1 point) Behavioral Disorder OCD, Anxiety in addition to

above(+1 point) Family/ Social

ComplicationsDivorce

(+1 point) Guardianship issues Guardianship not legally established

Total Complexity Score

Developed by The National Alliance to Advance Adolescent HealthAdapted from Chapel Hill Pediatrics

Evaluation: Medical Home Health Care Transition Index

• Indicator #1: Office health care transition (privacy and consent) policy

• Indicator #2: Staff and provider HCT knowledge and skills and coordination of care

• Indicator #3: Identification of transitioning youth/young adults (registries)

• Indicator #4: Transition preparation (readiness assessments)

• Indicator #5: Transition planning (transition plans)

• Indicator #6: Transfer of care or transition to adult model of careAssessments for pediatric and adult practicesEach HCT team self assess at baseline and 9 months4 levels for each indictor and 2 options (partial or complete) within each

indicator

Level 1 (Basic) Level 2 (Responsive)(Includes Level 1)

Level 3 (Proactive)(Levels 1 & 2)

Level 4 (Comprehensive)(Includes Levels 1, 2, 3)

Transition support and services vary among practice providers; staff members are informally aware of these supports and services; families/youth are informed of their individual clinician’s approach to transition as the youth’s needs arise.

There is a uniform, but not necessarily written, transition and transfer of care policy that is agreed upon by all providers and is made clear to staff; families/youth are informed of the office transition policy by age 18 and/or in response to inquiries prior to age 18.

A written transition and transfer of care policy addresses age of transition to adult model of care and (if necessary) age range for transfer to adult health care settings; the policy and its rationale are communicated to families/youth by age 12-14 during encounters and through brochures, posters, and website content

In addition to Level 3, the written health care transition and transfer of care policy addresses preparation, planning, process for transition to an adult model of care and transfer to adult health care settings. By age 18, guardianship, decision-making, and information access rights are determined and clearly identified in the medical record. Practice services include transition encounters, care coordination, & monitoring of steps/progress.

Pediatric Transition Index: #1 Office health care transitionpolicy: each level is rated Partial or Complete

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Health Care Transition Index ResultsDC Transition Project-Pediatric Practices

Baseline February 2011

Average scores of four practices: three pediatric, one family medicine

Core elements of health care transition

[Basic]

[Responsive]

[Proactive]

[Comprehensive]

DC LC Pediatric and Adult Practices HCT Index Data

Average total score for each element

Additional Transition Activities• LC spread within each institution• DC transition website –dctransition.org• Collaboration with HSCSN on CME and enduring CME• Collaboration with AJE on parent and youth transition training• Transition payment pilot with HSCSN• Transition and EPSDT with DHCF and new work gorup• Additional training to community health centers, school

nurses, etc.

Final Thoughts

Choose and Do…complete at least two health care transition improvements in the next month

• Ask the youth with SHCN in your practice if they are involved in doing household chores

• Read and share with staff the new AAP clinical report on HCT• Remove, copy, and post the algorithm• Discuss health care transition at office staff meeting• Identify responsible person/team for improving HCT in the office• Draft and adopt a Health Care Transition policy, share with staff, make visible to

and discuss with youth and families• Adopt a Health Care Transition checklist or agenda for office visits from age 14

and older• Actively support the identification of an adult/pediatric medical home practice

and develop open communication and plan transition/transfer processes to improve the transition process for all involved

Learning Objectives

• Define health care transition and related data from those involved in HCT

• List the key elements of the AAP/ACP/AAFP clinical report on practice-based implementation of transition planning for all youth beginning in early adolescence

• Discuss DC Learning Collaborative process and outcome

• Identify opportunities with one’s own practice for improvement in the transition of youth from pediatric to adult medical care

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Thank YouPwhite@arthritis.org

http://www.gottransition.org/

http://healthytransitionsny.comhttp://www.medicalhomeinfo.org/how/care_delivery/transitions.

aspx

http://www.childhealthdata.org/

http://nccc.georgetown.edu/

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www.fcsn.org www.fvkasa.org

??? NYLNwww.nyln.org/www.ncwd-youth.info/index.html