1. MCH Workforce Development
  2. Funded Projects

Funded Projects

Transitions from Pediatric to Adult Care with Access to a Medical Home

Project Website

Grant Status: Active

Training Category: Healthy Tomorrows Partnership for Children Program (HTPCP)

Project Director(s):

Tara Chadwell
Mountain States Health Alliance / Ballard Health
Johnson City, TN
Phone: 423-431-4891
FAX: 423-302-3448


Transitions from familiar pediatric care providers to adult care can be unsettling for children/adolescents with special health care needs and families as the child ages to adulthood, and coordination of care can also be complex without assistance.

Goals and Objectives:

Serve a minimum of 70 children with special health care needs annually

  • Establish a new program to support families/children with special health care needs transitioning from pediatric to adult care by hiring a Transition Coordinator to assist with these transitions; increase access to preventive care/services in the Medical Home; increase engagement in shared decision-making; assist with Structural and Social Determinants of Health (SSDOHs); and coordinate care to optimize health, quality of life, and well-being
  • Establish a Regional Advisory Board of families of patients, regional stakeholders, and care team members to provide project oversight, disseminate findings, and create a sustainability plan
  • Improve coordination with providers; Palliative Care; Medical Homes; Foster Care; and Emergency Rooms to improve patient/family-centered care; and schools to keep hospitalized children current on assignments and address 504 and Individualized Education Plans (IEP)
  1. Transition Coordinator hired within 60 days of Notice of Award (NoA)
  2. Regional Advisory Board formed within 90 days of NoA composed of members reflective of children/families served
  3. Utilize State Title V MCH Needs Assessments, Action Plans, and internal data to guide the project, with data findings discussed monthly at Regional Advisory Board meetings
  4. 50% increase annually of families engaged in shared decision-making via Shared Plans of Care as measured by Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey
  5. 100% of enrolled children have a Medical Home by Year 5 as measured by Pediatric Integrated Care Survey (PICS)
  6. Workforce training provided quarterly to relevant partners on pediatric to adult care transitions, and to schools on IEP and 504 Plan changes as each child ages up
  7. Sustainability plan created by Year 5
  8. Disseminate information and results/outcomes annually
  9. Form at least three new, collaborative relationships within 12 months of NoA
  10. Provide Community Resource Inventories tailored to each family’s SSDOH needs within 30 days of enrollment; include warm handoffs to services
  11. Expand use of telehealth and electronic Collaborative Care Plans; measured annually by number of appointments and plans created


Evidence-based strategies include the Biopsychosocial Model, Chronic Care Model, and Social Determinants of Health Model with integrated, team-based care centered around a Collaborative Care Plan that includes a Care Map, Care Notebook, Shared Plan of Care, and Youth-to-Adult Care Transition Workbook


The Transition Coordinator will utilize a Collaborative Care Plan standardized among providers to help with coordinating visits and providing patient- and family-centered care (the Plan includes health history and medication information); and will coordinate with schools to keep students current on assignments and/or advocate for IEP and 504 Plan changes


Models evaluated for success at Regional Advisory Board meetings so children/adolescents and families have direct input. Process and outcome measures used to gauge progress toward stated goals. Data used to make changes to the project based on evaluation results from the Continuous Quality Improvement (CQI) “Plan-Do-Study-Act” model. Other evaluation methods include Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Surveys; Press-Ganey patient surveys; and Pediatric Integrated Care Survey (PICS) Interviews