Transition Program

The Pennsylvania Medical Home Initiative – Transition Program is an extension of the larger program funded by the Pennsylvania Department of Health. Since 2010, the program has focused on helping pediatric and adult primary care providers develop and implement processes and tools in their practices to make it easier for Youth with Special Health Care Needs (YSHCN) and their families make the leap from pediatric primary care to adult-based primary care.

Pediatric practices that have implemented the Medical Home principles and model of care through PA-MHI are invited to participate in the Transition Program. To date, there are fifteen pediatric practices that are involved in the program.

The program helps the pediatric practices identify youth between the ages of 14 and 20+ who have special health care needs and are in an appropriate place to start the process of transitioning to an adult-based primary care provider. These patients are added to a Transition Registry so that the practice can follow their progress and make sure that the topic of transition is addressed at visits and certain tools, like the transition checklist, are given to them in a timely manner.

Adult-based primary care providers (Family Medicine and Internal Medicine) who are able to accept YSHCN are identified as partners for the pediatric practices. These practices work hand in hand with the pediatric practice to pave the way for a smooth transition for the patient and their family by communicating with the patient's pediatrician before the visit occurs. Patients on Medicaid can also use the DPW Operations Memorandum (OPs Memo) to see a potential adult-based provider before switching the capitation.

The Transition Program has two Parent Advisors on staff who serve as advocates and resources for the families of the transitioning youth. As parents of YSHCN themselves, these team members are in a position to help families prepare for and talk about the upcoming transition experience for their youth.