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PEDIATRICS Vol. 110 No. 6 December 2002, pp. 1322-1327

Implementing Transitions for Youth With Complex Chronic Conditions Using the Medical Home Model

Anne M. Kelly, MD, MPH, Barbara Kratz, RN, MS, CPNP, Mary Bielski, RN and Peggy Mann Rinehart, BA

From the University of Minnesota, Minneapolis, Minnesota

The concept of a medical home is endorsed as an effective model for implementing successful transitions for youth with complex chronic conditions. The U Special Kids program at the University of Minnesota is described as a medical home designed to improve service delivery for children and youth with complex medical conditions to help them achieve optimal health and functioning. Two case studies depict effective communication methods, including a concise written health history summary, that promote shared understanding of the adolescent’s and family’s strengths and their skills. Specific components of a transition plan are detailed with the recommendation that a formal assessment occur to develop an individualized transition plan. The individualized plan incorporates goals for the adolescent to gain independence and to obtain support in required areas.

Key Words: medical home • adolescent • transition • chronic illness

Abbreviations: AAP, American Academy of Pediatrics • MCHB, Maternal and Child Health Bureau • USK, U Special Kids (program)

Received for publication Jul 2, 2002; Accepted Aug 26, 2002.




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