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Patient Transition Goals

Top 10 Patient Transition Goals

 

  1. 3 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

    Por favor, identifica una o más metas en las que deseas trabajar este año.

    Para mi próxima visita anual a esta clínica voy a poder…

    1. Resumen de 3 frases – crear uno para describir mis problemas médicos y así revisarlos con mis proveedores.
    2. Historial médico y condición – poder describir mis condiciones médicas y cuidados que he necesitado.
    3. Medicamentos – proporcionar una lista a todos los proveedores externos, la enfermera de la escuela y la clínica de salud del campus universitario.
    4. Alcohol, Drogas, y Tabaco- explicar cómo estos productos pueden afectar mi problema médico.
    5. Atención de Emergencia y pedir ayuda– reconocer y decirle a otras personas cuando mis problemas de salud requieren atención de emergencia.
    6. Información de contacto/Seguro médico – traer conmigo mi tarjeta de seguro médico y una lista de proveedores en mi cartera o teléfono.
    7. Mi Pasaporte de Salud - crear y tener siempre una copia en mi cartera o mandar una copia a mi teléfono celular.
    8. Portal del Paciente – inscribirme y explorarlo.
    9. Opciones de Tutela Legal – trabajar con un abogado y las agencias para poder establecer la tutela legal con límite establecido, o completa, a la edad de 18 años.
    10. Proveedor para Adultos – trabajar con el equipo para encontrar y ponerme en contacto con un nuevo proveedor de atención médica para adultos.

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. 3 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 co-pays