Transition Toolkit



As a part of the Medical Home Implementation Project, TNAAP has developed a Transition Toolkit that can be used as an effective tool to assist providers and families in developing Transition plans for Children and Youth with Special Health Care Needs (CYSHCN).

Health care transition is the process of a patient and their family changing from a pediatric to an adult model of health care. The goal of transition is to optimize health and assist youth and their families in ensuring continuity of care. This process requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in care. We want to provide support and resources for providers as they implement their practice's Transition Planning.

It is important to have resources available for the physicians, the office staff and the families. The core elements in planning for a Transitions Policy:

  • Develop a Transitions Policy
  • Tracking and monitoring patients - establishing a register and using tracking templates.
  • Determining Transitions Readiness Evaluation for CYSHCN Patients and Families
  • Transition Planning coordinating with adult provider
  • Transfer of Care to an adult provider
  • Completion of Transfer of Care

Patients that have special health care needs have more positive outcomes from a fully developed Transitions Policy. It is an essential element in the care of CYSHNC and their families. We encourage you to check the website for more information and updates.


Slides for each presentation are also available for download. Click the link below each video to download the slides for that particular presentation.

Provider Resources

Center for HealthCare Transition Improvement: Got Transition

AAP Publication: Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home

IDD Toolkit: HealthCare for Adults with Developmental Disabilities-A Toolkit for Primary Care Providers

Association Of University Centers on Disabilities: Transition Planning for Adolescents with Special Health Care Needs and Disabilities: A Guide for Health Care Providers

National Center for Medical Home: Transitions

Medical Home Portal: Transition to Adulthood

Heath Resource Center at the National Youth Transitions Center: Homepage

Adolescent Health Transition Project: Homepage

Family Resources

Family Voices: Transition Planning

The ARC of Tennessee: Transition to Adulthood - Best Practices in the Secondary Transition Process

Tennessee Disability Pathfinder: Homepage

Vanderbilt Kennedy Center of Excellence on Intellectual and Developmental Disabilities: TRIAD Transition PlanningNext Steps

Support and Training for Exceptional Parents (STEP): Transition Services

Graduate School of Education and Human Development - The George Washington University: HEATH Resource Center at the National Youth Transition Center

Becoming Leaders for Tomorrow: Training for young adults, healthcare providers, families and disability service organization via videos-Leadership Toolkit

Tennessee Chapter American Academy of Pediatrics

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