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Patient Transition Goals

Top 10 Patient Transition Goals

 

  1. Three-sentence summary: Create to describe my medical problems to review with my providers.

  2. Medical history and condition: Be able to describe my medical condition and care I have needed.

  3. Medications: Provide a list to any outside providers, school nurse and college campus health clinic.

  4. Alcohol, drugs and tobacco: Explain how these could affect my medical problem.

  5. Emergency care and asking for help: Knowing when to ask for help when I have medical problems.

  6. Contact information/insurance: Keep insurance card and list of medical providers in phone/wallet.

  7. My Health Passport: Create and keep a copy in my wallet or copy it to my cell phone.

  8. Patient portal: Enroll in and explore.

  9. Guardianship options: Work with agencies and a lawyer to establish limited or full guardianship at age 18.

  10. Adult provider: Work with team to find and contact a new adult provider.

Additional goals to consider


Managing my own health

 

  1. Guardianship options: Work with agencies and a lawyer to establish limited or full guardianship at age 18.

  2. Legal documents: Complete a Durable Power of Attorney for Health Care and Health Care Treatment Directive.

  3. Medications: Take them independently.

  4. My Health Passport: Create and keep a copy in my wallet or copy it to my cell phone.

  5. Patient portal: Enroll in and explore.

  6. Prescription refills: Order them by myself.

  7. Release of information: Signing a form to allow parents/adult caregivers to access my records.

  8. School counselor: Work with my school counselor to learn about vocational rehabilitation programs.

  9. Telephone numbers: Create a list of my doctors, nurses, school nurse, case managers, important contacts.

  10. Transportation: Can schedule transportation to my medical appointment by myself.

  11. Wallet or cell phone: Keep a list of important numbers and medications in my wallet or cell phone.

Transfer of care to an adult provider

 

  1. Adult provider: Work with team to find and contact a new adult provider.

  2. Medications: Provide a list to any outside providers, school nurse and college campus health clinic.

  3. Mental health provider: Find a new adult provider.

  4. Peer mentor: Talk with someone who has moved to an adult provider who can help me with questions.

  5. Regional center: Describe what services I am receiving from the Regional Center.

  6. Release of information: Signing a form to transfer my records to a new provider.

  7. Tour adult provider: Set up a tour of an adult medical center and clinics where I plan to receive care.

  8. Transfer care orders: For home health, medical equipment, supplies, private-duty nursing to adult practitioners.

  9. Transition plan: Create plan with the medical or mental health team.

  10. Transition plan: Communicate to all the medical teams.

Understanding my medical condition

 

  1. Three-sentence summary: Create to describe my medical problems to review with my providers.

  2. Alcohol, drugs and tobacco: Explain how these could affect my medical problem.

  3. Ask for help: When to tell others how to help me with my medical problems when needed.

  4. Emergency care: Recognize and tell others when my health problem requires emergency care.

  5. Medical conditions: List.

  6. Medical history: Describe.

  7. Need medical care: Can tell my family or other adults when I am sick enough to contact my medical team.

  8. Sex/reproductive life: Explain how my medical problem could affect this.

Paying for my health care

  1. Dental coverage: Learn what dental care options are available if I don’t have dental coverage.

  2. Insurance card: Keep copies of my medical and dental cards in my wallet.

  3. Insurance changes: Talk with the medical team about any changes to my insurance.

  4. Prescription assistance: Work with the staff if I have no medical insurance coverage or need help with copays.