Different Healthcare Transition Models

  • Cecily L. Betz


This chapter will provide an overview of the structural aspects and processes that characterize healthcare transition (HCT) models. Comparisons and contrasts between HCT models that focus on the transfer of care and those that are more comprehensive in scope will be reviewed. Outcomes associated with the measurement of HCT service and adolescents and young adults with special healthcare needs will be discussed. Points of emphasis for clinical application are featured in the chapter tables and case example.


Transfer of care Healthcare transition Medical summary Clinical guidelines 


  1. 1.
    Magrab PR, Miller HEC, editors. Surgeon's General’s Conference: growing up and getting medical care: youth with special health care needs. A summary of conference proceedings. 1989 March 13–15. Jekyll Island, Georgia: National Center for Networking Community Based Services. Georgetown University Child Development Center; 1989.Google Scholar
  2. 2.
    Betz CL. Transition of adolescents with special health care needs: review and analysis of the literature. Issues Compr Pediatr Nurs. 2004;27:179–240.PubMedCrossRefGoogle Scholar
  3. 3.
    Betz CL, O'Kane LS, Nehring WM, Lobo ML. Systematic review: health care transition practice service models. Nurs Outlook 2016;64(3):229–243. PubMedPubMedCrossRefGoogle Scholar
  4. 4.
    Chu PY, Maslow GR, von Isenburg M, Chung RJ. Systematic review of the impact of transition interventions for adolescents with chronic illness on transfer from pediatric to adult healthcare. J Pediatr Nurs. 2015;30(5):e19–e27. PubMed Pubmed Central PMCID: NIHMS710745.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Bloom SR, Kuhlthau K, Van Cleave J, Knapp AA, Newacheck P, Perrin JM. Health care transition for youth with special health care needs. J Adolesc Health 2012;51(3):213–219. PubMed English.PubMedCrossRefGoogle Scholar
  6. 6.
    Coyne B, Hallowell SC, Thompson M. Measurable outcomes after transfer from pediatric to adult providers in youth with chronic illness. J Adolesc Health 2017;60(1):3–16. PubMedPubMedCrossRefGoogle Scholar
  7. 7.
    Binks JA, Barden WS, Burke TA, Young NL. What do we really know about the transition to adult-centered health care? A focus on cerebral palsy and spina bifida. Arch Phys Med Rehabil. 2007;88(8):1064–73.CrossRefGoogle Scholar
  8. 8.
    American Academy of Pediatrics American Academy of Family Practice, & American College of Physicians-American Society of Internal Medicine. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002;110(6 Pt 2):1304–6.Google Scholar
  9. 9.
    American Academy of Pediatrics, American Academy of Family Practice, American College of Physicians, Transitions Clinical Report Authoring G, Cooley WC, Sagerman PJ Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics 2011;128(1):182–200. PubMedGoogle Scholar
  10. 10.
    Society of Pediatric Nurses. SPN position statement: transition of pediatric patients into adult care. Chicago, Illinois: Society of Pediatric Nurses; 2016. p. 9.Google Scholar
  11. 11.
    Ludvigsson JF, Agreus L, Ciacci C, Crowe SE, Geller MG, Green PH, et al. Transition from childhood to adulthood in coeliac disease: the Prague consensus report. Gut 2016;65(8):1242–1251. PubMedPubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Suris JC, Akre C. Key elements for, and indicators of, a successful transition: an international Delphi study. J Adolesc Health 2015;56(6):612–618. PubMedPubMedCrossRefGoogle Scholar
  13. 13.
    Rosen DS, Blum RW, Britto M, Sawyer SM, Siegel DM. Transition to adult health care for adolescents and young adults with chronic conditions. J Adolesc Health. 2003;33(4):309–11.CrossRefGoogle Scholar
  14. 14.
    Baldassano R, Ferry G, Griffiths A, Mack D, Markowitz J, Winter H. Transition of the patient with inflammatory bowel disease from pediatric to adult care: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2002;34(3):245–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Geerlings RP, Aldenkamp AP, de With PH, Zinger S, Gottmer-Welschen LM, de Louw AJ. Transition to adult medical care for adolescents with epilepsy. Epilepsy Behav 2015;44:127–135. PubMedCrossRefGoogle Scholar
  16. 16.
    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
  17. 17.
    Betz CL, Smith KA, Van Speybroeck A, Hernandez FV, Jacobs RA. Movin’ on up: an innovative nurse-led interdisciplinary health care transition program. J Pediatr Health Care 2016;30(4):323–338. PubMedPubMedCrossRefGoogle Scholar
  18. 18.
    Bridgett M, Abrahamson G, Ho J. Transition, it's more than just an event: supporting young people with type 1 diabetes. J Pediatr Nurs. 2015;30(5):e11–e4.PubMedCrossRefGoogle Scholar
  19. 19.
    Ciccarelli MR, Gladstone EB, Armstrong Richardson EAJ. Implementation of a transdisciplinary team for the transition support of medically and socially complex youth. J Pediatr Nurs. 2015;30(5):661–7.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Woodward JF, Swigonski NL, Ciccarelli MR. Assessing the health, functional characteristics, and health needs of youth attending a noncategorical transition support program. J Adolesc Health 2012;51(3):272–278. PubMed English.PubMedCrossRefGoogle Scholar
  21. 21.
    McDonagh JE, Shaw KL, Southwood TR. Growing up and moving on in rheumatology: development and preliminary evaluation of a transitional care programme for a multicentre cohort of adolescents with juvenile idiopathic arthritis. J Child Health Care 2006;10(1):22–42. .PubMed English.PubMedCrossRefGoogle Scholar
  22. 22.
    Dabadie A, Troadec F, Heresbach D, Siproudhis L, Pagenault M, Bretagne JF. Transition of patients with inflammatory bowel disease from pediatric to adult care. Gastroenterol Clin Biol. 2008;32(5 Pt 1):451–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Vanelli M, Caronna S, Adinolfi B, Chiari G, Gugliotta M, Arsenio L. Effectiveness of an uninterrupted procedure to transfer adolescents with Type 1 diabetes from the paediatric to the adult clinic held in the same hospital: eight-year experience with the parma protocol. Diabetes Nutr Metab 2004;17(5):304–308. PubMedGoogle Scholar
  24. 24.
    Bhawra J, Toulany A, Cohen E, Moore Hepburn C, Guttmann A. Primary care interventions to improve transition of youth with chronic health conditions from paediatric to adult healthcare: a systematic review. BMJ Open 2016;6(5):e011871. PubMedPubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Bollegala N, Nguyen GC. Transitioning the adolescent with IBD from pediatric to adult care: a review of the literature. Gastroenterology Research & Practice 2015;2015:853530. PubMedCrossRefGoogle Scholar
  26. 26.
    Embrett MG, Randall GE, Longo CJ, Nguyen T, Mulvale G. Effectiveness of health system services and programs for youth to adult transitions in mental health care: a systematic review of academic literature. Adm Policy Ment Health 2016;43(2):259–269. PubMedCrossRefGoogle Scholar
  27. 27.
    Peter NG, Forke CM, Ginsburg KR, Schwarz DF. Transition from pediatric to adult care: internists' perspectives. Pediatrics. 2009;123(2):417–23.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    DiIorio C, Shafer PO, Letz R, Henry TR, Schomer DL, Yeager K. Behavioral, social, and affective factors associated with self-efficacy for self-management among people with epilepsy. Epilepsy Behav. 2006;9(1):158–63.PubMedCrossRefGoogle Scholar
  29. 29.
    DiIorio C, Osborne Shafer P, Letz R, Henry T, Schomer DL, Yeager K. The association of stigma with self-management and perceptions of health care among adults with epilepsy. Epilepsy Behav. 2003;4(3):259–67.PubMedCrossRefGoogle Scholar
  30. 30.
    Sawin KJ, Brei T, Holmbeck G. The development of the adolescent\young adult self-management and independence scale-AMIS II: psychometric data. 2017.Google Scholar
  31. 31.
    Sawin, KJ, Bellin, M, Woodward, J,Brei, T. Self-management in spina bifida: a synthesis in literature. Paper presented at the Third World Congress on Spina Bifida Research and Care; 2017 March 16–19; San Diego, CAGoogle Scholar
  32. 32.
    Holmes-Walker DJ, Llewellyn AC, Farrell KA. transition care programme which improves diabetes control and reduces hospital admission rates in young adults with Type 1 diabetes aged 15–25 years. Diabet Med. 2007;24(7):764–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Smith GM, Lewis VR, Whitworth E, Gold DT, Thornburg CD. Growing up with sickle cell disease: a pilot study of a transition program for adolescents with sickle cell disease. J Pediatr Hematol Oncol 2011;33(5):379–382. PubMedPubMedCrossRefGoogle Scholar
  34. 34.
    Wiener LS, Kohrt B, Battles HB, Pao M. The HIV experience: youth identified barriers for transitioning from pediatric to adult care. J Pediatr Psychol. 2011;36(2):141–54.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Betz CL, Lobo ML, Nehring WM, Bui K. Voices not heard: a systematic review of adolescents' and emerging adults’ perspectives of health care transition. Nurs Outlook 2013;61(5):311–336. PubMedPubMedCrossRefGoogle Scholar
  36. 36.
    Betz CL, Nehring WM, Lobo ML. Transition needs of parents of adolescents and emerging adults with special health care needs and disabilities. J Fam Nurs 2015;21(3):362–412. PubMedPubMedCrossRefGoogle Scholar
  37. 37.
    Agency for Healthcare Quality and Research. Care Coordination Rockville, MD: Agency for Healthcare Research and Quality. 2016 [updated July 2016; cited 15 October 2017].
  38. 38.
    Blomquist K, Brown G, Peersen A, Presler E. Transitioning to independence: challenges for young people with disabilities and their caregivers. Orthop Nurs. 1998;17(3):27–35.PubMedCrossRefGoogle Scholar
  39. 39.
    Blomquist KB. Healthy and ready to work: Kentucky: incorporating transition into a state program for children with special health care needs. Pediatr Nurs 2006;32(6):515–528. PubMedGoogle Scholar
  40. 40.
    Lerret SM, Menendez J, Weckwerth J, Lokar J, Mitchell J, Alonso EM. Essential components of transition to adult transplant services: the transplant coordinators' perspective. Prog Transplant 2012;22(3):252–258. PubMedPubMedCrossRefGoogle Scholar
  41. 41.
    Rogers K, Zeni MB. Systematic review of medical home models to promote transitions to primary adult health care for adolescents living with autism spectrum disorder. Worldviews Evid Based Nurs 2015;12(2):98–107. PubMedPubMedCrossRefGoogle Scholar
  42. 42.
    Annunziato RA, Baisley MC, Arrato N, Barton C, Henderling F, Arnon R, et al. Strangers headed to a strange land? A pilot study of using a transition coordinator to improve transfer from pediatric to adult services. J Pediatr 2013;163(6):1628–1633. PubMedPubMedCrossRefGoogle Scholar
  43. 43.
    Betz CL, Redcay G. Dimensions of the transition service coordinator role. J Soc Pediatr Nurs 2005;10(2):49–59. PubMedPubMedCrossRefGoogle Scholar
  44. 44.
    Jivanjee P, Kruzich J. Supports for young people with mental health conditions and their families in the transition years: youth and family voices. Best Prac Ment Health. 2011;7:115–33.Google Scholar
  45. 45.
    Jivanjee P, Kruzich JM, Gordon LJ. The age of uncertainty: parent perspectives on the transition of young people with mental health difficulties to adulthood. J Child Fam Stud. 2009;18:435–46.CrossRefGoogle Scholar
  46. 46.
    Kieckhefer GM, Trahms CM, Churchill SS, Simpson JN. Measuring parent-child shared management of chronic illness. Pediatr Nurs. 2009;35(2):101–8.PubMedGoogle Scholar
  47. 47.
    Kieckhefer GM, Trahms CM. Supporting development of children with chronic conditions: from compliance toward shared management. Pediatr Nurs 2000;26(4):354–363. PubMedGoogle Scholar
  48. 48.
    Stinson JN, Toomey PC, Stevens BJ, Kagan S, Duffy CM, Huber A, et al. Asking the experts: exploring the self-management needs of adolescents with arthritis.[see comment]. Arthritis Rheum. 2008;59(1):65–72.PubMedCrossRefGoogle Scholar
  49. 49.
    Heath G, Farre A, Shaw K. Parenting a child with chronic illness as they transition into adulthood: a systematic review and thematic synthesis of parents’ experiences. Patient Educ Couns 2017;100(1):76–92. PubMedPubMedCrossRefGoogle Scholar
  50. 50.
    Andreoni KA, Forbes R, Andreoni RM, Phillips G, Stewart H, Ferris M. Age-related kidney transplant outcomes: health disparities amplified in adolescence. JAMA Intern Med 2013;173(16):1524–1532. PubMed English.PubMedCrossRefGoogle Scholar
  51. 51.
    Allen D, Channon S, Lowes L, Atwell C, Lane C. Behind the scenes: the changing roles of parents in the transition from child to adult diabetes service. Diabet Med 2011;28(8):994–1000. PubMedPubMedCrossRefGoogle Scholar
  52. 52.
    Hess JS, Straub DM. Brief report: preliminary findings from a pilot health care transition education intervention for adolescents and young adults with special health care needs. J Pediatr Psychol 2010;36(2):172–178. PubMedPubMedCrossRefGoogle Scholar
  53. 53.
    Scott L, Vallis M, Charette M, Murray A, Latta R. Transition of care: researching the needs of young adults with type 1 diabetes. Can J Diabetes. 2005;29:203–10.Google Scholar
  54. 54.
    Betz CL, Ferris ME, Woodward JF, Okumura MJ, Jan S, Wood DL. The health care transition research consortium health care transition model: a framework for research and practice. J Pediatr Rehabil Med 2014;7(1):3–15. PubMedGoogle Scholar
  55. 55.
    Ihara ES, Wolf-Branigin M, White P. Quality of life and life skill baseline measures of urban adolescents with disabilities. Soc Work Public Health 2012;27(7):658–670. PubMed English.PubMedCrossRefGoogle Scholar
  56. 56.
    Yorkery B, Test DW. Improving educational outcomes and post-school success for students with disabilities. N C Med J 2009;70(6):542–544. PubMedGoogle Scholar
  57. 57.
    Rosen D. Between two worlds: bridging the cultures of child health and adult medicine. J Adolesc Health 1995;17(1):10–16. PubMedPubMedCrossRefGoogle Scholar
  58. 58.
    Okumura MJ, Heisler M, Davis MM, Cabana MD, Demonner S, Kerr EA. Comfort of general internists and general pediatricians in providing care for young adults with chronic illnesses of childhood. J Gen Intern Med 2008;23(10):1621–1627. PubMedPubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    Nehring WM, Betz CL, Lobo ML. Uncharted territory: systematic review of providers' roles, understanding, and views pertaining to health care transition. J Pediatr Nurs 2015;30(5):732–747. PubMedPubMedCrossRefGoogle Scholar
  60. 60.
    Arnett JJ. Emerging adulthood. a theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469–80.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Arnett JJ, Tanner JL. Emerging adults in America. Coming of age in the 21st century. American Psychological Association: Washington, D.C; 2006.CrossRefGoogle Scholar
  62. 62.
    Camfield P, Camfield C, Pohlmann-Eden B. Transition from pediatric to adult epilepsy care: a difficult process marked by medical and social crisis. Epilepsy Currents 2012;12(Suppl 3):13–21. PubMedPubMedPubMedCentralCrossRefGoogle Scholar
  63. 63.
    Cadario F, Prodam F, Bellone S, Trada M, Binotti M, Trada M, et al. Transition process of patients with type 1 diabetes (T1DM) from paediatric to the adult health care service: a hospital-based approach. Clin Endocrinol (Oxf) 2009;71(3):346–350. PubMedPubMedCrossRefGoogle Scholar
  64. 64.
    Jurasek L, Ray L, Quigley D. Development and implementation of an adolescent epilepsy transition clinic. J Neurosci Nurs 2010;42(4):181–189. PubMedPubMedCrossRefGoogle Scholar
  65. 65.
    Pyatak EA, Carandang K, Vigen C, Blanchard J, Sequeira PA, Wood JR, et al. Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) study: methodology and baseline characteristics of a randomized controlled trial evaluating an occupation-based diabetes management intervention for young adults. Contemp Clin Trials 2017;54:8–17. PubMedPubMedPubMedCentralCrossRefGoogle Scholar
  66. 66.
    Wafa S, Nakhla M. Improving the transition from pediatric to adult diabetes healthcare: a literature review. Can J Diabetes 2015;39(6):520–528. PubMedPubMedCrossRefGoogle Scholar
  67. 67.
    Hazel E, Zhang X, Duffy CM, Campillo S. High rates of unsuccessful transfer to adult care among young adults with juvenile idiopathic arthritis. Pediatr Dent 2010;8:2. PubMedPubMedPubMedCentralCrossRefGoogle Scholar
  68. 68.
    Steinbeck KS, Shrewsbury VA, Harvey V, Mikler K, Donaghue KC, Craig ME, et al. A pilot randomized controlled trial of a post-discharge program to support emerging adults with type 1 diabetes mellitus transition from pediatric to adult care. Pediatr Diabetes 2015;16(8):634–639. PubMedPubMedCrossRefGoogle Scholar
  69. 69.
    Betz CL, Smith K. Measuring health care transition planning outcomes: challenges and issues. Int J Child Adolesc Health. 2010;3:463–72.Google Scholar
  70. 70.
    Le Roux E, Mellerio H, Guilmin-Crepon S, Gottot S, Jacquin P, Boulkedid R, et al. Methodology used in comparative studies assessing programmes of transition from paediatrics to adult care programmes: a systematic review. BMJ Open 2017;7(1):e012338. PubMedPubMedPubMedCentralCrossRefGoogle Scholar
  71. 71.
    Kipps S, Bahu T, Ong K, Ackland FM, Brown RS, Fox CT, et al. Current methods of transfer of young people with Type 1 diabetes to adult services. Diabet Med. 2002;19(8):649–54.PubMedPubMedCentralCrossRefGoogle Scholar
  72. 72.
    Gleeson H, Turner G. Transition to adult services. Arch Dis Child Educ Pract Ed 2012;97(3):86–92. PubMed English.CrossRefGoogle Scholar
  73. 73.
    Bolton-Maggs PH. Transition of care from paediatric to adult services in haematology. Arch Dis Child. 2007;92(9):797–801.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Harden PN, Walsh G, Bandler N, Bradley S, Lonsdale D, Taylor J, et al. Bridging the gap: an integrated paediatric to adult clinical service for young adults with kidney failure. BMJ 2012;344:e3718. PubMed English.PubMedPubMedCentralCrossRefGoogle Scholar
  75. 75.
    Watson AR. Non-compliance and transfer from paediatric to adult transplant unit. Pediatr Nephrol. 2000;14(6):469–72.PubMedCrossRefGoogle Scholar
  76. 76.
    Shaw KL, Southwood TR, McDonagh JE, British Society of Paediatric and Adolescent Rheumatology. Development and preliminary validation of the ‘Mind the Gap’ scale to assess satisfaction with transitional health care among adolescents with juvenile idiopathic arthritis. Child Care Health Dev. 2007;33(4):380–8.PubMedPubMedCentralCrossRefGoogle Scholar
  77. 77.
    Shaw KL, Southwood TR, McDonagh JE, British Society of Paediatric and Adolescent Rheumatology. Young people's satisfaction of transitional care in adolescent rheumatology in the UK. Child Care Health Dev. 2007;33(4):368–79.PubMedCrossRefGoogle Scholar
  78. 78.
    Reid GJ, Irvine MJ, McCrindle BW, Sananes R, Ritvo PG, Siu SC, et al. Prevalence and correlates of successful transfer from pediatric to adult health care among a cohort of young adults with complex congenital heart defects. Pediatrics. 2004;113(3 Pt 1):e197–205.PubMedCrossRefGoogle Scholar
  79. 79.
    Betz CL, Redcay G. An exploratory study of future plans and extracurricular activities of transition-age youth and young adults. Issues Compr Pediatr Nurs. 2005;28(1):33–61.PubMedCrossRefGoogle Scholar
  80. 80.
    Di Rezze B, Nguyen T, Mulvale G, Barr NG, Longo CJ, Randall GE. A scoping review of evaluated interventions addressing developmental transitions for youth with mental health disorders. Child Care Health Dev 2016;42(2):176–187. PubMedGoogle Scholar
  81. 81.
    Prior M, McManus M, White P, Davidson L. Measuring the “triple aim” in transition care: a systematic review. Pediatrics 2014;134(6):e1648–e1661. PubMedCrossRefGoogle Scholar
  82. 82.
    Institute for Healthcare Improvement (IHI). IHI triple aim initiative. Better care for individuals, better health for populations, and lower per capita costs (n.d.) [cited 2017 April 15].
  83. 83.
    Sheehan AM, While AE, Coyne I The experiences and impact of transition from child to adult healthcare services for young people with Type 1 diabetes: a systematic review. Diabet Med 2015;32(4):440–458. PubMedPubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PediatricsUniversity of Southern California (USC), Keck School of MedicineLos AngelesUSA
  2. 2.USC University Center for Excellence in Developmental DisabilitiesChildren’s Hospital Los AngelesLos AngelesUSA

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