Heartland Transition Project
Project Description:
The Medical Home has been instrumental in promoting a successful transition for youth with special health care needs from pediatric to adult medical care. Increasing numbers of youth with special health care needs are leaving school and living quality lives with the appropriate medical care as a result of this initiative. Additionally, the medical community including pediatric, family, and primary care offices and clinics are expanding their services to include the Medical Home and experiencing the benefits that coordinated and comprehensive care can provide. Families and youth with special health care needs themselves, report satisfaction with the Medical Home and the assistance they receive with orchestrating the transition to new systems of care.
Despite the advantages reported by youth, families, and the medical community with the Medical Home, the opportunity for transition services from pediatric to adult medical care are significantly lacking for the majority of the population. For many, the services are inadequate and do not result in the intended outcomes of quality care, coordinated services, and successful and productive adult lives. In addition, transition services are often fragmented and delivered in isolation of the other systems with responsibility for transition for youth with special health care needs resulting in duplication or gaps in service delivery and confusion for the very people they were designed to serve.
The Heartland Collaborative proposes to address this problem through the development of an integrated, interagency youth transition model involving the medical, education, and rehabilitation service delivery systems. The purpose of this demonstration project is to build on the successful components of these service delivery systems to achieve a transition
model that results in quality post-secondary outcomes for youth with special health care needs across all domains. Unique to this model will be the integration of transition services by a health care transition navigator and an education transition coordinator within the IEP and Medical Home processes to address adult and health-related issues for youth with special health care needs enabling them to receive the supports they need to manage their medical care and live, work, and participate in their communities.
Keyword(s):
health care transition, medical home, learning collaborative
Core Function(s):
Performing Technical Assistance and/or Training, Performing Research or Evaluation
Area of Emphasis
Health-Related Activities
Target Audience:
Professionals and Para-Professionals, Family Members/Caregivers, Children/Adolescents with Disabilities/SHCN
Unserved or Under-served Populations:
None
Primary Target Audience Geographic Descriptor:
Regional
COVID-19 Related Data:
N/A
