Examples from the Field

  • Connecticut’s Community Health Center, Inc., with its network of over 100 SBHCs across the state, created a Transition Age Youth (TAY) playbook with templates from the Six Core Elements of HCT embedded in their EHR.
  • Michigan’s Department of Health and Human Services partnered with the Blue Devil Wellness Center in Wakefield, Michigan, an SBHC run by the health department of Northwest Michigan, to replicate an SBHC transition project based on the Six Core Elements of HCT.

What health care transition tools did you customize for your HCT program?

  • CT: The HCT tools we are using include a transition policy, a registry, a transition readiness assessment, and a transition plan of care. We created a Transition Age Youth (TAY) playbook with these tools and embedded them as templates into our clinic processes and EHR dashboard. Behavioral and medical providers receive alerts when and if a TAY is needed for young adolescents preparing for the transition. This alert also identifies specific high-risk populations, including those with complex care needs.
  • MI: The HCT tools we are using include a welcome and care policy, a transition readiness assessment, a medical care and emergency plan summary, and a resource for finding an adult doctor for students leaving the school.

Who was part of your SBHC quality improvement team for your HCT Program?

  • CT: We involved the chief medical officer, chief behavioral health officer, chief of pediatrics, nursing officer, product manager, senior quality improvement team, the business intelligence team, senior EHR analyst, SBHC regional directors, and SBHC clinical staff.
  • MI: We involved the section manager for policy and program development and the transition specialist from the state of Michigan’s Children’s Special Health Care Services. Also, from the state, we involved the nurse and clinic managers for the School-Based Health Section within the Child and Adolescent Health Section. An administrative representative from the local public health department was also involved in overseeing the school clinic activities. Clinic staff involved included the administrative/medical assistant, nurse, and social worker.

What population of students did your HCT intervention serve (e.g., all high school students, juniors and seniors only, etc.)?

  • CT: Initially, our SBHCs focused on adolescents 17 and older with behavioral health conditions. The TAY effort has now expanded to all adolescent patients ages 13-21 with behavioral health conditions. We are also in the process of expanding our TAY process to our school medical providers.
  • MI: Our pilot targeted junior and senior students in a rural SBHC.

What would you say is the most important component and/or tool of your HCT intervention for students?

  • CT: We found that having conversations with the providers regarding the tools for transitioning to an adult model of care was very important. In addition, having a TAY care module with Transition Readiness, Transition Planning, and Transition of Care and Transfer Completion was helpful to standardize the approach along with adding transition recommendations and discharge information to the care plan template.
  • MI: The most important component for the students in our pilot was the transition readiness assessments. Students were engaged in the process and were surprised to consider all of the different aspects of health care transition.

What advice do you have for others implementing HCT in schools for the first time?

  • CT: Start the process with a reasonable number of students, depending on the organization’s size. Consider starting with an identified high-risk patient population, such as those with complex care needs and/or behavioral health needs, as these patients will likely require added support and facilitated linkages to adult care. Begin the transition care plan and continue transition discussions in subsequent visits. Embed the process into the current process for care delivery and leverage the entire care team. Continue training providers/clinicians on implementing new strategies to remove any gaps in care needed for transition.
  • MI: Utilize existing tools as much as possible. It streamlines the process so clinics can focus on working with students. Maximize the engagement of the medical assistant in the process as part of the implementation. In our pilot, the medical assistant had the most time with the students. In addition, their rapport and trust with students were significant in the success of the pilot.