Health Care Transition for Youth: What Social Workers Need to Know
Carrie Dorn, MPA, LMSW, Senior Practice Associate, Health
December 2024
As youth age into adulthood, they typically transition from pediatric medical services to adult providers when they are between 18 and 24 years old. It is important for young adults to engage with adult providers independently as new issues emerge, such as substance use, mental health, and sexual health concerns. To prepare youth for this transition, a Health Care Transition (HCT) planning process should take place with youth and their families beginning around age 12 to 14. Pediatric hospitals and practices should develop organizational policies, including a timeline, for transitioning adolescents to adult services depending on the needs of the population served. The interdisciplinary health care team, including physicians, nurses, and social workers, can work together to ensure that youth continue to receive care from the appropriate clinician during the transition process.
The challenges and opportunities of this stage have been
studied and addressed by several medical societies and provider groups, with
particular attention to adolescent patients with chronic and complex medical
conditions.
Social
workers should be aware of the evidence base around health care transitions for
youth, and social workers in health care teams can support patients and
families to prepare for these transitions.
Pediatric Model of Care vs. Adult Model of Care
The pediatric care model is family-centered and involves parents and caregivers in decision-making. Parents and caregivers may take the lead in planning for health care needs by scheduling visits, managing medication, and accompanying children to appointments. For younger children with chronic and/or complex health conditions, the pediatric team, including social workers, may coordinate care and serve as a liaison between specialists.
In contrast, the adult model of care is person-centered and the patient develops a relationship with providers independently. In adult services, the individual is responsible for making appointments, scheduling follow ups, and managing medication. In addition, providers that serve adults may no longer prioritize care coordination with specialists, and this responsibility may shift to the young person.
Six Core Elements of Health Care Transition™
In 2018, and again in 2023, the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and American College of Physicians (ACP) issued clinical reports calling for attention to the Health Care Transition (HCT) process for youth. Most young people in the U.S. do not receive preparation for this transition, and as a result, youth may face barriers to leaving their pediatric practices and building skills for self-management of their health.
Got Transition®,
a program of The National Alliance to Advance Adolescent Health, is the
national resource center on HCT. HCT is a structured model that can be
implemented in practices to prepare providers, youth and families/caregivers for
these transitions.
The six elements include:
- Develop a transition care policy/guide to inform providers, youth, and families
- Establish criteria and processes to identify and deliver transition planning to youth
- Assess transition readiness through assessment and education
- Conduct transition planning in collaboration with youth and family
- Identify adult providers and transition care
- Follow up with youth and family to confirm transfer completion
Social Work Role
In pediatric settings, social workers can lead the process to help youth prepare for their transition to adult care. Social workers can help youth, families, and providers anticipate the benefits and challenges that will come with the transition. There are also unique considerations for youth with disabilities and special health care needs to ensure that they have access to support and health insurance coverage as they transition into adulthood.
As described in the NASW Standards for the Practice of Social Work with Adolescents, social workers help adolescents achieve self-empowerment by developing independent living skills, encouraging them to be active participants in their care, and assuming responsibility for managing services.While many youth and pediatric providers feel strong attachments to working together, staying in pediatric care can be a disservice to the youth. It’s a benefit to youth to build skills to manage their own health care, and social workers can assist in setting transition timelines that families and providers are comfortable with. Building independent relationships with adult providers can also help youth ages 18 to 24 have confidential, private discussions around sensitive topics such as mental health conditions, substance use issues, peer and romantic relationships, reproductive health, family dynamics, and health-related social needs. Some elements of the transition process that social workers provide include:
- Providing resources/handouts to help youth summarize health history
- Supporting youth to describe one’s health conditions and needs
- Holding individual meetings to discuss transition planning and assess the need for adult primary care providers and specialists
- Helping young adults secure health insurance coverage
- Individual and family counseling as needed
- Locating and selecting adult providers
- Supporting communication/transfer of health information to adult practices
- Helping to address barriers to care in adult practices
Resources for Social Workers:
- The National Alliance to Advance Adolescent Health, Got Transition https://www.gottransition.org/six-core-elements/
- Got Transition, Health Care Transition Timeline for Youth and Young Adults
- Children’s Mercy Kansas City, Transition to Adulthood Resources | Children's Mercy Kansas City (childrensmercy.org)
- Children’s Hospital of Philadelphia, Transition to Adulthood Services
- The National Alliance to Advance Adolescent Health, A National Report: Youth and Young Adults with Disabilities Aging Out of Medicaid, CHIP, SSI, and Title V Programs Barriers, Inequities, and Recommendations
- Children’s Mercy Kansas City, Outcomes of a Structured Ambulatory Care Health Care Transition Approach in a Large Children's Hospital - PubMed (nih.gov)
- Implementing a Nationally Recognized Pediatric-to-Adult Transitional Care Approach in a Major Children’s Hospital
- National Association of Pediatric Nurse Practitioners NAPNAP Position Statement on Supporting the Transition from Pediatric to Adult-Focused Health Care (jpedhc.org)
- Transition to Adulthood for Youth With Chronic Conditions and Special Health Care Needs - Journal of Adolescent Health (jahonline.org)
- Evaluation of a Health Care Transition Improvement Process in Seven Large Health Care Systems - Journal of Pediatric Nursing: Nursing Care of Children and Families
- American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Transitions Clinical Report Authoring Group, Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home