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©2013 UpToDate ® Print Email Components of transition for adolescents with special health care needs within the medical home model* Maintain the adolescent in the home or community whenever possible Identify the individual who will be responsible for assessing health status Establish a plan for communication with the health care provider Organize critical information and make it accessible Assess the adolescent's ability to provide an accurate medical history Shift the responsibility for information management from the parent to the adolescent or other responsible adult Identify the collaborating team Reassess the need for specialty and subspecialty care Assess the family/adolescent's readiness to make the transition to adult specialist(s) Develop a plan for the transition of care to new physicians Develop a formal process to say "goodbye" to valued, established health care providers Coordinate care with family, home, and community providers Reassess the developmental appropriateness of current community services Determine whether there are unmet needs Assess the need for formal evaluation that will help to identify areas of strength and areas where support will be required Coordinate subspecialty service of value to the family Assess capacity of adolescent to assume responsibility for coordination of care Begin to transfer responsibility to the adolescent and allow time for him or her to "practice" this responsibility Reassign responsibility for areas of needed support * The needs are on a continuum based upon the skills and abilities of the adolescent. Adapted from: Kelly AM, Kratz B, Bielski M, Rinehart PM. Implementing transitions for youth with complex chronic conditions using the medical home model. Pediatrics 2002; 110:1322.