title: Implementing transitions for youth with complex chronic conditions using the medical home model.
abstract: The concept of a medical home is endorsed as an effective model for implementing successful transitions for youth with complex chronic conditions. The U Special Kids program at the University of Minnesota is described as a medical home designed to improve service delivery for children and youth with complex medical conditions to help them achieve optimal health and functioning. Two case studies depict effective communication methods, including a concise written health history summary, that promote shared understanding of the adolescent's and family's strengths and their skills. Specific components of a transition plan are detailed with the recommendation that a formal assessment occur to develop an individualized transition plan. The individualized plan incorporates goals for the adolescent to gain independence and to obtain support in required areas.
authors.affiliation: University of Minnesota, Minneapolis, Minnesota 55455-2009, USA.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Kelly
authors.forename: Barbara
authors.initials: B
authors.lastname: Kratz
authors.forename: Mary
authors.initials: M
authors.lastname: Bielski
authors.forename: Peggy Mann
authors.initials: PM
authors.lastname: Rinehart
mesh_terms: D000293:Adolescent; D016497:Adolescent Health Services / Q000458:organization & administration*; D000328:Adult; D002648:Child; D002662:Child Health Services / Q000458:organization & administration*; D002908:Chronic Disease / Q000628:therapy*; D003266:Continuity of Patient Care; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D020380:Needs Assessment; D010347:Patient Care Planning / Q000458:organization & administration; D010348:Patient Care Team / Q000458:organization & administration; D014481:United States