Paeds · adolescent-and-young-adult-medicine
Transition readiness and transfer from paediatric to adult health services
Also known as Health-care transition · Transition to adult care · Transfer of care · Transition readiness · Got Transition Six Core Elements · TRAQ transition readiness assessment · Paediatric to adult handoff
A fellowship approach to transition readiness and transfer from paediatric to adult health services: defining transition as a purposeful staged process distinct from transfer; applying the Got Transition Six Core Elements; assessing readiness across self-management, navigation, communication, legal and psychosocial domains with tools such as the TRAQ; building a portable medical summary and emergency plan; organising a warm handoff to a named adult primary and specialty home; managing chronic-condition populations (diabetes, congenital heart disease, cystic fibrosis, IBD, sickle cell disease, complex/technology-dependent and neurodevelopmental disability); re-engaging youth lost to follow-up; and comparing ANZ, UK, US and Canadian service models.
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Target exams
Red flags
- Abrupt 'birthday discharge' at 18 with no adult clinic secured and no portable summary
- Young adult lost to follow-up after paediatric discharge presenting with disease relapse or diabetic ketoacidosis
- Acute mental-health crisis, self-harm or safeguarding concern surfacing at the service boundary
- Medication or device (insulin pump, home ventilation, feeding tube) failure after transfer with no adult plan
- Family/carers in crisis or burnout at the age-of-majority legal and funding boundary
- Disclosure of a transition-related safeguarding risk: coercion, neglect, or exploitation of a dependent young adult
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Adolescent and young adult health
- Long-term conditions and chronic disease management
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Renewed curriculum for first-year trainees from 2027 — Learning goal 14: Quality and safety; systems-based practice
- Adolescent medicine and transition to adult care
- Professional practice, care coordination and systems improvement
- General and Adolescent Paediatrics
- Clinical Applications — care of adolescents and young adults with chronic conditions
- Systems of care, transition and care coordination
- Long Cases — adolescent with a chronic condition approaching transfer
- Communication stations — counselling a young person and family about transition
- Structured discussion of transition planning and adult-service handoff
- 2. Professional skills and knowledge: Communication
- 4. Professional skills and knowledge: Patient management
- 5. Health promotion and illness prevention
- 11. Adolescent health and long-term conditions
- Leadership and team working — care coordination across the service boundary
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Adolescent health, chronic illness and transition
- History
- Communication
- Clinical — chronic-disease long case
- General Pediatrics Content Outline — Domain 1: Preventive Pediatrics/Well-Child Care
- General Pediatrics Content Outline — Domain 10: Chronic and complex conditions; systems of care
- General Pediatrics Content Outline — Domain 11: Adolescent Medicine
- General Pediatrics EPA 3: Providing well-child and adolescent care including anticipatory guidance
- General Pediatrics EPA: Transition care for children and youth with special health care needs
- Patient Care 5: Patient Management — chronic-condition care across the transition boundary
- Systems-Based Practice 3: System Navigation for Patient Centered Care – Coordination of Care and transitions
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Professionalism 1: Professional Behavior and Ethical Principles
- Practice-Based Learning and Improvement — transition quality improvement
- Medical Expert
- Communicator
- Collaborator
- Leader
- Health Advocate
- Pediatrics EPA — transition planning for youth with chronic conditions
Overview & Definition
A 17-year-old with type 1 diabetes has not seen an adult team and has no transition plan. At 18 the paediatric service sends a referral letter and stops. Eight months later he presents in diabetic ketoacidosis, having run out of insulin and never made it to adult clinic. This is the failure mode the whole topic exists to prevent, and it is common wherever transfer is treated as an administrative event rather than a clinical process. [12]
Health-care transition is the purposeful, planned movement of a young person from child-centred to adult-oriented health care, with continuous services before, during and after the move. Transfer is only one event inside that process — the administrative handoff of care and records to a named adult provider. Conflating the two is the central error. Transition can succeed with a transfer that is well prepared, and it can fail badly with a transfer that happens on a birthday with no preparation. [1] [2]
Why does the boundary matter so much? Adolescence is when a young person must take over the work their family has been doing — booking appointments, carrying the diagnosis, managing medicines, navigating an adult system — while also completing growth, education and identity formation. A chronic condition layers onto that developmental task. The paediatric model is family-led and coordinator-rich; the adult model expects the patient to lead and offers far less scaffolding. Without a bridge, the young person falls into the gap between two models that were never designed to meet. [1] [4]
The evidence is clear on two points. First, structured transition programmes improve engagement, disease-specific knowledge, satisfaction and self-management skills compared with usual care. Second, the unstructured default — age-based discharge with no adult home — produces loss to follow-up, relapse, and avoidable acute presentations, particularly in the youngest, most complex and least-supported young people. [6] [9]
The arc of a good transition
- 1
Introduce early
Start a transition policy by 11–12 years; normalise the idea with the young person and family.
- 2
Assess readiness
Use a validated tool (TRAQ) yearly as a teaching map, not a pass/fail gate.
- 3
Plan & document
Portable summary, emergency plan, adult provider search, legal and insurance preparation.
- 4
Transfer with a warm handoff
Named adult primary and specialty home; joint visit or direct introduction, not a cold letter.
- 5
Confirm integration
Verify first adult visit happened; short post-transfer follow-up; rescue if lost to follow-up.
References12ShowHide
- [1]White PH; Cooley WC Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 2018.PMID 30348754
- [2]Cooley WC, Sagerman PJ Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics, 2011.PMID 21708806
- [3]Sawicki GS; Lukens-Bull K; Yin X; Demars N; Huang IC; Livingood W; Reiss J; Wood D Measuring the transition readiness of youth with special healthcare needs: validation of the TRAQ--Transition Readiness Assessment Questionnaire. Journal of pediatric psychology, 2011.PMID 20040605
- [4]Suris JC; Akre C Key elements for, and indicators of, a successful transition: an international Delphi study. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 2015.PMID 26003575
- [5]Suris JC; Larocca S; Akre C; Ambresin AE; Bel M; Kaufmann M; Paglia L; Roux N; Vidal C Transition from paediatric to adult care: what makes it easier for parents? Child: care, health and development, 2017.PMID 27625071
- [6]Gabriel P; McManus M; Rogers G; White P Outcome Evidence for Structured Pediatric to Adult Health Care Transition Interventions: A Systematic Review. The Journal of pediatrics, 2017.PMID 28668449
- [7]Fortune J; Cowan K; McClean L; Stelfox L; Stebbins A; Westrop C; Morris C Transition to adulthood: Perspectives from young people with cerebral palsy, parents, and health professionals. Developmental medicine and child neurology, 2026.PMID 42277597
- [8]Campbell F; Biggs K; Aldiss SK; O'Neill PM; Clowes M; McDonagh J; While A; Gibson F Transition of care for adolescents from paediatric services to adult health services. Cochrane Database of Systematic Reviews, 2016.PMID 27128768
- [9]Schmidt A; Ilango SM; McManus MA; Rogers KK; White PH Outcomes of Pediatric to Adult Health Care Transition Interventions: An Updated Systematic Review. Journal of pediatric nursing, 2020.PMID 31981969
- [10]Ilango SM; Schmidt A; McManus MA; Lemke KW; White PH Disparities in Health Care Transition Preparation Among US Youth. Pediatrics, 2025.PMID 40953840
- [11]Osunkwo I; Andemariam B; Beebe D; Mvula I; Riel R; Tanabe P; Walker A; Coyne I; Joshi S; Sharma D; Enderis M; Peugh J; Adams RJ; Britto MT; Anderson LM Results of a healthcare transition learning collaborative for emerging adults with sickle cell disease: the ST3P-UP study transition quality improvement collaborative. BMJ quality & safety, 2025.PMID 39577868
- [12]Lotstein DS; Seid M; Klingensmith G; Case D; Lawrence JM; Pihoker C; Cruz E; Anderson A; Peters AL; Wysocki T; Waitzfelder B; Bell RA; Todd L; Donnelly T; Dabelea D; Beck RW; Ponder S; Majcher S; Sivaprasad L; Deeb L; Laffel L; Holmbrook J; Greenbaum C; Blevins P; Goyer S; Fox LA; D'Agostino J; Foster N; Kollman C; Libman I; Lipman TH; Massias C; Maturo AC; Nadeau K; Petitti DB; Rodriguez-Vega D; Simmons JH; Tfayli H; Willi SM; Writing Group for the SEARCH for Diabetes in Youth Study Transition from pediatric to adult care for youth diagnosed with type 1 diabetes in adolescence. Pediatrics, 2013.PMID 23530167