Establishing a Method to Monitor Transition Planning and Track Patient Outcomes Following Transfer

  • Gregory Sawicki


Tracking patient progress, transition planning, and patient outcomes before, during, and after transfer are critical components of any healthcare transition program. Creating and maintaining a transition data registry can serve to facilitate these processes for a clinician or healthcare practice. This chapter reviews the key components of a transition registry, including the purpose of a registry, why it is important to track healthcare transition preparation processes, the necessary steps in establishing and maintaining a registry, the various uses of a registry, and the value of a registry in tracking population-based measures for practice-based quality improvement.


Patient progress Transition planning Patient outcomes Transfer HCT 


  1. 1.
    American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians; Transitions Clinical Report Authoring Group, Cooley WC, Sagerman PJ. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011;128(1):182–200.CrossRefGoogle Scholar
  2. 2.
    Gliklich RE, Dreyer NA, Leavy MB, editors. Registries for evaluating patient outcomes: a user’s guide [Internet]. 3rd ed. Rockville, MD: Agency for Healthcare Research and Quality (US); 2014. Google Scholar
  3. 3.
    Schechter MS, Fink AK, Homa K, Goss CH. The Cystic Fibrosis Foundation Patient Registry as a tool for use in quality improvement. BMJ Qual Saf. 2014;23(Suppl 1):i9–14.PubMedCrossRefGoogle Scholar
  4. 4.
  5. 5.
    Peterson A, Hanberger L, Akesson K, Bojestig M, Andersson Gäre B, Samuelsson U. Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden. PLoS One. 2014;9(5):e97875.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Harris JG, Bingham CA, Morgan EM. Improving care delivery and outcomes in pediatric rheumatic diseases. Curr Opin Rheumatol. 2016;28(2):110–6.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Tyson MD, Barocas DA. Improving quality through clinical registries in urology. Curr Opin Urol. 2017;27(4):375–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Clauss SB, Anderson JB, Lannon C, Lihn S, Beekman RH, Kugler JD, Martin GR. Quality improvement through collaboration: the National Pediatric Quality improvement Collaborative initiative. Curr Opin Pediatr. 2015;27(5):555–62.PubMedCrossRefGoogle Scholar
  9. 9.
    McManus M, White P, Barbour A, Downing B, Hawkins K, Quion N, Tuchman L, Cooley WC, McAllister JW. Pediatric to adult transition: a quality improvement model for primary care. J Adolesc Health. 2015;56(1):73–8.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    McManus M, White P, Pirtle R, Hancock C, Ablan M, Corona-Parra R. Incorporating the six core elements of health care transition into a Medicaid managed care plan: lessons learned from a pilot project. J Pediatr Nurs. 2015;30(5):700–13.CrossRefGoogle Scholar
  11. 11.
  12. 12.
    Wiemann CM, Hergenroeder AC, Bartley KA, Sanchez-Fournier B, Hilliard ME, Warren LJ, Graham SC. Integrating an EMR-based transition planning tool for CYSHCN at a Children’s Hospital: a quality improvement project to increase provider use and satisfaction. J Pediatr Nurs. 2015;30(5):776–87.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Hergenroeder AC, Wiemann CM, Bowman VF. Lessons learned in building a hospital-wide transition program from pediatric to adult-based health care for youth with special health care needs (YSHCN). Int J Adolesc Med Health. 2016;28(4):455–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Zhang LF, Ho JS, Kennedy SE. A systematic review of the psychometric properties of transition readiness assessment tools in adolescents with chronic disease. BMC Pediatr. 2014;14:4.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Fair C, Cuttance J, Sharma N, Maslow G, Wiener L, Betz C, Porter J, McLaughlin S, Gilleland-Marchak J, Renwick A, Naranjo D, Jan S, Javalkar K, Ferris M, International and Interdisciplinary Health Care Transition Research Consortium. International and interdisciplinary identification of health care transition outcomes. JAMA Pediatr. 2016;170(3):205–11.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Sawicki GS, Garvey KC, Toomey SL, Williams KA, Chen Y, Hargraves JL, Leblanc J, Schuster MA, Finkelstein JA. Development and validation of the adolescent assessment of preparation for transition: a novel patient experience measure. J Adolesc Health. 2015;57(3):282–7.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Respiratory Diseases, Department of MedicineBoston Children’s Hospital, Harvard Medical SchoolBostonUSA

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