title: Implementation and sustainability of statewide transition support services for youth with intellectual and physical disabilities.
abstract: OBJECTIVE
  Significant gaps in care and limited existing models establish the need to innovate systems of care for youth with special health care needs in the transition between pediatric to adult health care settings.
  
  
  METHODS
  Using implementation science, a statewide transition support program was created. University and community partners explored needs and adopted a strategic plan and funding sources. The existing consensus statement provided a framework. A team was hired, policies were piloted and the initial ambulatory consultative transition service for youth with special needs ages 11 to 22 was launched. Full program activities during year four were analyzed.
  
  
  RESULTS
  During 2011, there were 139 consultations for youth with intellectual disability and/or physical disability (average 16.74 years, 46% female). Services include routine and focused co-morbidity screening and recommendations, care coordination of complex health and community service needs, and support for families. The evolving transdisciplinary team adapted their methods to collaborate with a growing population of youth and primary care providers.
  
  
  CONCLUSIONS
  A statewide transition support program is a viable delivery model to provide needed resources for youth, families and primary care practices. Weekly improvement meetings continue to adapt services to sustain family satisfaction and community provider satisfaction.
authors.affiliation: Departments of Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Mary R
authors.initials: MR
authors.lastname: Ciccarelli
authors.affiliation: Indiana University Center for Youth and Adults with Conditions of Childhood, Indianapolis, IN, USA.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Brown
authors.affiliation: Indiana University Center for Youth and Adults with Conditions of Childhood, Indianapolis, IN, USA.
authors.forename: Erin B
authors.initials: EB
authors.lastname: Gladstone
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
authors.forename: Jason F
authors.initials: JF
authors.lastname: Woodward
authors.affiliation: Departments of Public Health and Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Swigonski
mesh_terms: D000293:Adolescent; D002648:Child; D002908:Chronic Disease / Q000534:rehabilitation*; D003695:Delivery of Health Care / Q000458:organization & administration*; D006233:Persons with Disabilities / Q000534:rehabilitation*; D005260:Female; D066086:Health Services for Persons with Disabilities / Q000458:organization & administration*; D006801:Humans; D008607:Intellectual Disability / Q000534:rehabilitation*; D008297:Male; D060305:Transition to Adult Care / Q000458:organization & administration*; D055815:Young Adult
keywords: Adolescent health services; consultation and referral; implementation science; intellectual disability; physical disability; program development; transition to adult care; youth with special health care needs