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About This Project

ACP’s Council of Subspecialty Societies (CSS) initiated a project to develop specialized toolkits to facilitate more effective transition and transfer of young adults into the adult health care setting.

Recognizing that gaps often occur in the transition process for emerging adults as they transition from pediatric to adult health care, in particular for youth with special health needs, ACP’s Council of Subspecialty Societies (CSS) initiated a project to develop specialized toolkits to facilitate more effective transition and transfer of young adults into the adult health care setting. This effort is under the direction of ACP’s Council of Subspecialty Societies (CSS) in collaboration with Got Transition (GT)/Center for Health Care Transition Improvement, a cooperative agreement between the Maternal and Child Health Bureau and the National Alliance to Advance Adolescent Health, Society of General Internal Medicine (SGIM), and Society of Adolescent Health and Medicine (SAHM).  The initiative is chaired by Carol Greenlee, MD, FACP. This project is also part of the College’s High Value Care Coordination Project —a part of ACP’s broader high value care initiative — which attempts to help physicians to provide the best possible care to their patients while simultaneously reducing unnecessary costs to the healthcare system.

Based on the joint clinical recommendations from the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Got Transition/Center for Health Care Transition Improvement developed an evidence-informed model, Six Core Elements of Health Care Transitions, which includes free sample tools that  clinicians can download and implement in their offices. These core elements were used as a basis for the development of disease-specific tools through the ACP Pediatric to Adult Care Transitions Initiative, which are accessible on this site.

CSS member organizations were asked to provide volunteers to customize three tools for patients with a disease/condition of their choosing who would benefit from improved care transitions as an emerging adult. “Subgroups” consisting of adult and pediatric physicians along with appropriate representation from other clinical organizations and patients and family were established to develop the customized tools.  The validated generic tools from the Got Transition Six Core Elements were used as a formatting guide, but sub groups were allowed to adapt tool formats and content to meet the perceived unique needs of their patients, families and clinical teams. 

The customized tools were reviewed by the ACP Pediatric to Adult Care Transitions Initiative Steering Committee, consisting of representation from primary and specialty care internal medicine, medicine-pediatrics, adolescent medicine and Got Transition leadership. The tools were also reviewed by the American Academy of Pediatrics (AAP) specialty groups. Organizations involved in the subgroup that developed each set of tools are listed on the page containing the tools. 

Participating Organizations

CSS organizations that participated in this project

  • Alliance of Academic Internal Medicine (AAIM)
  • American Academy of Allergy, Asthma & Immunology (AAAAI)
  • American Academy of Neurology (AAN)
  • American Association of Clinical Endocrinologists (AACE)
  • American College of Allergy, Asthma and Immunology (ACAAI)
  • American College of Cardiology (ACC)
  • American College of Gastroenterology (ACG)
  • American College of Physicians (ACP)
  • American College of Rheumatology (ACR)
  • American Geriatrics Society (AGS)
  • American Society of Hematology (ASH)
  • American Society of Nephrology (ASN)
  • American Thoracic Society (ATS)
  • Endocrine Society (ES)
  • Infectious Disease Society of America (IDSA)
  • Renal Physicians Association (RPA)
  • Society for Adolescent Health and Medicine (SAHM)
  • Society of Critical Care Medicine (SCCM)
  • Society of General Internal Medicine (SGIM)

Additional Participating Organizations

  • American Academy of Family Physicians (AAFP)
  • American Academy of Pediatrics (AAP)
  • American Association of Nurse Practitioners (AANP)
  • American Osteopathic Association (AOA)
  • Child Neurology Foundation (CNF)
  • Got Transition/Center for Health Care Transition Improvement (GT)
  • Institute for Patient- and Family-Centered Care (IPFCC)
  • Medicine-Pediatrics Program Directors Association (MPPDA)
  • National Partnership for Woman and Families (NPWF)