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Medical Home & Care Coordination for Providers

A medical home is a patient-centered approach to providing comprehensive, coordinated and high quality primary care. It involves organized care across all elements of the broader health care system, and includes active collaboration between families and their health care professionals. Building medical home capacity not only helps providers address patients’ medical needs – it also helps them address patient challenges related to social determinants of health (i.e. access to housing, food, education, transportation, employment and more) through expanded community referral networks. 

Youth Health Transition (YHT) is care coordination specifically for emerging adults as they change from a pediatric to an adult model of care. Health care transition services help assist youth in reaching their full potential and ensure their best possible health. Coordinated care, including youth health transition, is valuable to all patient populations, but is essential for meeting the needs of special health care populations. To transition to an adult model of care successfully, teens and young adults should receive support in the following:

  • Acquiring independent life skills
     
  • Preparing for the kinds of health care they’ll need as adults
  • Transferring to new providers without disruption of care

Youth who are not transitioned to adult care, may face the following consequences:

  • Difficulty accessing health care
  • Increased impairment, morbidity, or mortality
  • Decreased function or mobility
  • Increased health care costs
  • Decreased likelihood that the individual will reach social milestones

For technical assistance on implementing YHT into your practice, contact cshsprogram@la.gov.

 
National Resource Center for Patient/Family-Centered Medical Home

Medical practices can take on a medical home approach to provide better care for their patients. Learn more about how to incorporate a medical home approach into your practice and talk with your patients and their families about the benefits of care coordination. 

 

Care Coordination Toolkit

Use this toolkit to learn more about the importance of care coordination and how to improve or implement it into your practice. This is a great resource for creating a more comprehensive service for you and your patients!

 

Youth Health Transition Checklist and Timeline 

Embedding a youth transition checklist into your practice helps support a coordinated and consistent workflow. This checklist provides a standardized framework for documenting and tracking comprehensive youth health transition services at a clinic. It also includes referrals related to insurance, habitation, school, and work programs.  

 

Youth Health Transition Toolkit

This toolkit is for health care or social service professionals working with teens and young adults who want to integrate youth health transition (YHT) services into their regular clinic practice. It is based on clinical practice guidelines from national experts and lessons learned from the field.

 

Resources to Share with Patients & Families 

Insurance Fact Sheet

Help your patients better understand their health insurance plan and what to look for when trying to find care. Click here for Spanish version. 

 

Getting Ready for Transition

A readiness assessment and planning tool to help teens and their families prepare for the transition into adult healthcare. 

 

Youth Health Transition Fact Sheet

A brief description of what YHT is, how to prepare, and what your patients will need to succeed when they transition their care. Click here for Spanish version.

 

Smooth Moves  

SmoothMovesYHT.org is an online transition resource for teens. The website seeks to orient youth to the process of transition, create role awareness, and provide access to resources tailored for transition-aged youth. There are over 30 transition tools and workbooks embedded within the site developed by expert workgroups and universities around the country. 

 

Got Transition

GotTransition.org includes a compendium of publications and resources on youth health transition and includes comprehensive provider toolkits for implementing transition services at the practice level.