Maintain the adolescent in the home or community whenever possible |
Identify the individual who will be responsible for assessing health status |
Establish a plan for communication with the health care provider |
Organize critical information and make it accessible |
Assess the adolescent's ability to provide an accurate medical history |
Shift the responsibility for information management from the parent to the adolescent or other responsible adult |
Identify the collaborating team |
Reassess the need for specialty and subspecialty care |
Assess the family/adolescent's readiness to make the transition to adult specialist(s) |
Develop a plan for the transition of care to new physicians |
Develop a formal process to say "goodbye" to valued, established health care providers |
Coordinate care with family, home, and community providers |
Reassess the developmental appropriateness of current community services |
Determine whether there are unmet needs |
Assess the need for formal evaluation that will help to identify areas of strength and areas where support will be required |
Coordinate subspecialty service of value to the family |
Assess capacity of adolescent to assume responsibility for coordination of care |
Begin to transfer responsibility to the adolescent and allow time for him or her to "practice" this responsibility |
Reassign responsibility for areas of needed support |
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