http://www.hivcareforyouth.org/adol?page=md-module&mod=03-tb-01

Providers' Transition Checklist and Timeline

Providers' Transition Checklist and Timeline
 Ages 14-16Ages 17-19Ages 20-24
Healthcare
Meet privately with the youth for part of the office visitXXX
Encourage the youth to assume increasing responsibility for own health care management

  • Ensure that the youth understands own health condition and medications

XXX

  • Send copies of reports, letters, and tests to the youth and family

XXX
Provide anticipatory guidance

  • Nutrition and fitness

XXX

  • Sexuality and relationships

XXX

  • Substance abuse and smoking

XXX
Assess the youth and family's readiness for transfer to an adult health care provider

  • Initiate discussion about transfer to an adult care provider

XXX

  • Identify possible adult care providers

 XX

  • Encourage patient to meet and interview adult providers

 XX

  • Initiate communication with the adult provider that the patient has selected

 XX
Implement the transfer to an adult primary care HIV provider

  • Transfer medical records

 XX

  • Discuss nuances of care with the adult care giver

 XX

  • Follow-up after transfer

 XX
Assess the youth's ability to make independent decisions regarding health care, finances, and other adult concerns for determining whether there is a need for guardianship/conservatorship or further education

  • Initiate referral for assessment of competence if needed (psychiatric services)

 XX

  • Provide medical documentation

 XX

  • Follow up on the process

 XX
Education
Ask the youth and family how you can participate in the individualized education program planning processXXX
Focus on the youth's course of study as it relates to long-term plans and goalsXXX
Discuss with the youth plans for further education beyond high school and assist with the appropriate resources to meet those goalsXXX
Employment
Initiate discussion of different routes to employment such as higher education or technical trainingXXX
Encourage the youth to explore community vocational opportunities and to become familiar with vocational services, even if further education is plannedXXX
Discuss with the youth and family the importance of early work experiences and job-related skills such as résumé preparation and interviewingXXX
Remind the youth and family that individualized transition planning should focus on developing a vision for employment and educationX  
Encourage the youth and family to contact local and state agencies involved in employment services; also consult your social workerXXX
Recreation
Discuss in home and community recreation optionsXXX
Assist in the development of strategies to foster friendships and avoid social isolation; assist in social networks such as support groups and peer facilitator training to mentor other youthXXX
Share health care information that may affect the youth's ability to participate in recreational activitiesXXX
Adapted from the Institute for Community Inclusion at Children's Hospital, Boston, as part of the Massachusetts Initiative for Youth with Disabilities #HO1MC00006 (Title V, Social Security Act).
Note: Providers may modify the checklist and timeline as developmentally appropriate for individual youth patients. Use clinical judgment in determining which items apply to each patient.