August 7, 2019

CMAG Case Management Adherence Guidelines. Version 2.0

Case Management Society of America. Case Management Adherence Guidelines. Version 2.0.http://www.cmsa.org/portals/0/pdf/CMAG2.pdf.Published June 2006. Accessed 7/9/14. Guidelines form the case Management Society of America for improving patient adherence to medication therapies
Case Management Society of America. Case Management Adherence Guidelines. Version 2.0.http://www.cmsa.org/portals/0/pdf/CMAG2.pdf.Published June 2006. Accessed 7/9/14. Guidelines form the case Management Society of America for improving patient adherence to medication therapies
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http://www.cmsa.org/portals/0/pdf/CMAG2.pdf

August 7, 2019

Medicaring.org

Altarum Institute. Medicaring.org. [Web site]. http://medicaring.org/Updated 2013. Accessed July 30, 2014. Medicaring is the exciting idea that Americans can learn to build reliable, effective, and efficient arrangements for services to support one another when we must live with serious chronic conditions, mostly associated with older age or the last years […]
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Altarum Institute. Medicaring.org. [Web site]. http://medicaring.org/Updated 2013. Accessed July 30, 2014. Medicaring is the exciting idea that Americans can learn to build reliable, effective, and efficient arrangements for services to support one another when we must live with serious chronic conditions, mostly associated with older age or the last years of life — and that such a care system will be substantially different from what we have now. We are working on policy, economics, professional development, public education, community demonstrations and a dozen other fronts to learn what works and to forge the commitment to change.
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Palliative Care, End-of-Life

August 7, 2019

National Association of Social Workers, Case Management Society of America, and NTOCC Case/Care Management Guidelines.

National Association of Social Workers, Case Management Society of America, and NTOCC Case/Care Management Guidelines. http://www.cmsa.org/portals/0/pdf/publiccomment/DraftCareCaseManagementGuidelines.pdf. Draft Published June 2007. Accessed 7/9/14. These guidelines are proposed to provide a framework for assessment to facilitate both transitions between levels of care and communication among professionals and with clients. Examples include Assessment […]
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National Association of Social Workers, Case Management Society of America, and NTOCC Case/Care Management Guidelines. http://www.cmsa.org/portals/0/pdf/publiccomment/DraftCareCaseManagementGuidelines.pdf. Draft Published June 2007. Accessed 7/9/14. These guidelines are proposed to provide a framework for assessment to facilitate both transitions between levels of care and communication among professionals and with clients. Examples include Assessment and Coordination of Care Communication Checklist.
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http://www.cmsa.org/portals/0/pdf/publiccomment/DraftCareCaseManagementGuidelines.pdf

August 7, 2019

Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach

Leonhardt K , Pagel P, Bonin D, et al. Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach. Http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-leonhardt_35.pdf. 2007. Accessed 7/9/14. Aurora Health Care partnered with Consumers Advancing Patient Safety (CAPS) and Midwest Airlines to implement a patient partnership model as an intervention to improve […]
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Leonhardt K , Pagel P, Bonin D, et al. Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach. Http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-leonhardt_35.pdf. 2007. Accessed 7/9/14. Aurora Health Care partnered with Consumers Advancing Patient Safety (CAPS) and Midwest Airlines to implement a patient partnership model as an intervention to improve medication safety in the outpatient setting. Bringing patients and health care providers together with a common goal offered the opportunity for collaboration and insight to the needs of our patients.
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http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-leonhardt_35.pdf

August 7, 2019

Joint Commission Center for Transforming Healthcare Releases Tool to Tackle Miscommunication Among Caregivers

The Joint Commission Center for Transforming Healthcare released a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related […]
The Joint Commission Center for Transforming Healthcare released a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related errors.
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http://www.centerfortransforminghealthcare.org/center_transforming_healthcare_tst_hoc/

August 7, 2019

One Patient, Many Places: Managing Health Care Transitions. A Report from the HMO Workgroup on Care Management

HMO Workgroup on Care Management. One Patient, Many Places: Managing Health Care Transitions. AAHP-HIAA Foundation, Washington DC. http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf . Published February 2004. This report addresses how Managed Care Organizations can improve the quality of transitions of care for adult patients with complex acute or chronic conditions. Includes best practices, recommendations […]
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HMO Workgroup on Care Management. One Patient, Many Places: Managing Health Care Transitions. AAHP-HIAA Foundation, Washington DC. http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf . Published February 2004. This report addresses how Managed Care Organizations can improve the quality of transitions of care for adult patients with complex acute or chronic conditions. Includes best practices, recommendations for action, and tools.
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http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf

August 7, 2019

NTOCC: Cultural Competence—Essential Ingredient for Successful Transitions of Care

Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered transitions of care. This tool provides information about culture and cultural competence, […]
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Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered transitions of care. This tool provides information about culture and cultural competence, as well as strategies and resources to enhance professionals’ capacity to deliver culturally competent services during transitions of care.
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http://www.ntocc.org/Portals/0/PDF/Resources/CulturalCompetence.pdf

August 7, 2019

Care management of patients with complex health care needs: Research Synthesis Report No. 19

Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April 17, 2013. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people […]
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Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April 17, 2013. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people with complex health care needs. This synthesis addresses the following questions: 1. What is care management? 2. How are patients identified for care management programs? 3. Do research-based care management programs enhance quality and reduce costs for patients with complex health care needs? 4. What are the characteristics of successful care management programs? 5. How have research-based care management programs been adapted to real-world treatment settings? 6. How do payment policies influence the creation and success of care management programs?
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https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1

August 7, 2019

Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project

Jaen CR, et al.Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Annals of Family Medicine.2010;8(S-1):S57-S67. http://www.annfammed.org/content/8/Suppl_1/S57.abstract .Accessed 7/10/14 PURPOSE The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices’ transition to patient-centered medical homes (PCMHs).
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Jaen CR, et al.Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Annals of Family Medicine.2010;8(S-1):S57-S67. http://www.annfammed.org/content/8/Suppl_1/S57.abstract .Accessed 7/10/14 PURPOSE The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices’ transition to patient-centered medical homes (PCMHs).
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http://www.annfammed.org/cgi/content/abstract/8/Suppl_1/S57

August 7, 2019

Personal Health Record

Coleman E. The Care Transitions Program®. Personal Health Record. http://www.caretransitions.org/documents/phr.pdf [No date specified]. Accessed 7/10/14.
Coleman E. The Care Transitions Program®. Personal Health Record. http://www.caretransitions.org/documents/phr.pdf [No date specified]. Accessed 7/10/14.
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http://www.caretransitions.org/documents/phr.pdf

August 7, 2019

One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management

Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are cared for in multiple care settings and by healthcare professionals of varied specialties and disciplines. Such dynamic events increase the risk of patients experiencing poor quality of care, especially as a […]
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Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are cared for in multiple care settings and by healthcare professionals of varied specialties and disciplines. Such dynamic events increase the risk of patients experiencing poor quality of care, especially as a result of medical errors and unsafe situations. Care coordination has been emphasized recently as a strategy for enhancing the effectiveness of care during such necessary transitions. This article describes the issue of care transitions and suggests how case management, through care coordination, can play an important role in ensuring safe and effective care transitions.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx

August 7, 2019

Effective Interventions to Reduce Hospitalizations: A Compendium of 15 Promising Interventions

Boutwell A, Griffin F, Hwu S, Shannon D. Institute for Healthcare Improvement. Effective Interventions to Reduce Hospitalizations: A Compendium of 15 Promising Interventions. http://ah.cms-plus.com/files/STAAR_A_Compendium_of_Promising_Interventions.pdf. 2009 . Accessed June 30, 2012. This document is intended to provide a sampling of the range of effective programs underway to reduce hospitalizations.
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Boutwell A, Griffin F, Hwu S, Shannon D. Institute for Healthcare Improvement. Effective Interventions to Reduce Hospitalizations: A Compendium of 15 Promising Interventions. http://ah.cms-plus.com/files/STAAR_A_Compendium_of_Promising_Interventions.pdf. 2009 . Accessed June 30, 2012. This document is intended to provide a sampling of the range of effective programs underway to reduce hospitalizations.
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http://ah.cms-plus.com/files/STAAR_A_Compendium_of_Promising_Interventions.pdf

August 7, 2019

AMDA Universal Transfer Form

AMDA. Universal Transfer Form. Tool. http://www.amda.com/tools/universal_transfer_form.pdf. Published 2007. Accessed July 24, 2014. AMDA has developed and recommends the use of the Universal Transfer Form (UTF) to facilitate the transfer of necessary patient information from one care setting to another. Patient transfers are fraught with the potential for errors stemming from […]
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AMDA. Universal Transfer Form. Tool. http://www.amda.com/tools/universal_transfer_form.pdf. Published 2007. Accessed July 24, 2014. AMDA has developed and recommends the use of the Universal Transfer Form (UTF) to facilitate the transfer of necessary patient information from one care setting to another. Patient transfers are fraught with the potential for errors stemming from the inaccurate or incomplete transfer of patient information. Use of the UTF can help to minimize the occurrence of such errors by ensuring that patient information is transmitted fully and in a timely fashion.
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http://www.amda.com/tools/universal_transfer_form.pdf

August 7, 2019

Multidisciplinary approach to inpatient medication reconciliation in an academic setting

PURPOSE The effectiveness of a multidisciplinary medication reconciliation process was studied in an inpatient family medicine unit of an academic hospital center. METHODS In phase 1 of this two-phase study, nurses, pharmacists, and physicians used an admission medication reconciliation form to reconcile patients’ home medications on admission. The form was […]
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PURPOSE The effectiveness of a multidisciplinary medication reconciliation process was studied in an inpatient family medicine unit of an academic hospital center. METHODS In phase 1 of this two-phase study, nurses, pharmacists, and physicians used an admission medication reconciliation form to reconcile patients' home medications on admission. The form was then reviewed by the pharmacist on the unit and by the attending physician, who reconciled the discharge medication list. The discharge medication list was compared against the patient's home medications list, inpatient medication profile, and prescriptions documented in the electronic medical record to investigate any medication discrepancies. Pharmacists participating in the study documented and categorized medication discrepancies by the potential severity of the error. In phase 2, family medicine medical residents and staff were instructed to include reconciled admission and discharge medication lists in the hospital summary. RESULTS A total of 102 patients formed the study sample. There was no significant difference between phase 1 and phase 2 patients in mean age, sex, and length of hospital stay. Totals of 432 and 367 admission medications required reconciliation during phase 1 and phase 2, respectively. The mean number of admission medication discrepancies decreased from 0.5 per patient in phase 1 to 0 per patient in phase 2. The mean number of discharge medication discrepancies decreased from 3.3 per patient in phase 1 to 1.8 per patient in phase 2. CONCLUSION The mean number of medication discrepancies occurring during admission and discharge decreased after a multidisciplinary medication reconciliation process was implemented in an inpatient family medicine unit of an academic hospital center.
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http://www.ncbi.nlm.nih.gov/pubmed/17420202?dopt=AbstractPlus

August 7, 2019

The Joint Commission National Patient Safety Goals

During 2009, the National Patient Safety Goals underwent an extensive review process. As a result, The Joint Commission has revised the NPSGs. The changes were made partly in response to concerns from the field about the resources needed to comply with NPSGs that have become more specific and detailed over […]
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During 2009, the National Patient Safety Goals underwent an extensive review process. As a result, The Joint Commission has revised the NPSGs. The changes were made partly in response to concerns from the field about the resources needed to comply with NPSGs that have become more specific and detailed over time. The revisions include clarifying and streamlining certain elements of performance, as well as deleting some requirements and moving others to the standards. The changes to the NPSGs reflect The Joint Commission’s continuing efforts to focus the NPSGs on those topics that are of highest priority to patient safety and quality care. Decreasing the number of NPSGs allows organizations to focus their efforts on the most important issues. Moving a requirement to the standards means that it is no longer necessary to “spotlight” the issue in the NPSGs. The improvements are similar to the Standards Improvement Initiative (SII), which the standards have undergone, and the goal of the improvements is to clarify language and ensure relevancy to the settings in which they apply. 2011 NPSG # 8: Accurately and completely reconcile medications across the continuum of care.
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http://www.jointcommission.org/standards_information/npsgs.aspx

August 7, 2019

Defining and disseminating the hospital-at-home model CMAJ January 20, 2009 180:156-157

The hospital, which is the “gold standard” for the delivery of acute medical care, is not an ideal care environment for many patients. Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common. New functional impairment commonly occurs during hospital stay. Suboptimal transitions in care at the […]
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The hospital, which is the "gold standard" for the delivery of acute medical care, is not an ideal care environment for many patients. Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common. New functional impairment commonly occurs during hospital stay. Suboptimal transitions in care at the time of hospital discharge also occur, contributing, ironically, to readmission to hospital. Furthermore, hospital care is very expensive. In this issue, Shepperd and colleagues present a meta-analysis of the effectiveness of "hospital-at-home programs."
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http://www.cmaj.ca/cgi/content/full/180/2/156

August 7, 2019

TJC Sentinel Event Alert: Using medication reconciliation to prevent errors

The Joint Commission recognizes that many patients may be too ill, injured, young, or disabled to actively participate in the medication reconciliation process. In addition, patients may need the assistance of another person (e.g., family member, significant other, surrogate decision maker) if they are overwhelmed in managing their condition, are […]
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The Joint Commission recognizes that many patients may be too ill, injured, young, or disabled to actively participate in the medication reconciliation process. In addition, patients may need the assistance of another person (e.g., family member, significant other, surrogate decision maker) if they are overwhelmed in managing their condition, are not proficient in speaking or reading English, or face health literacy challenges that might prevent them from understanding medication use directions. Therefore, the following addition should be included in the section titled "Joint Commission requirements and recommendations." Addendum to Sentinel Event Alert #35, Using medication reconciliation to prevent errors (#4) When the patient is unable to actively or fully participate in the medication reconciliation process and has requested assistance from another person(s) (e.g., family member, significant other, surrogate decision maker), involve the authorized person(s) in the medication reconciliation process. This involvement should occur at all interfaces of care, and on admission to and discharge from the facility.
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http://www.jointcommission.org/assets/1/18/SEA_35.PDF

August 7, 2019

Challenges in transitional care between nursing homes and emergency departments

OBJECTIVE To obtain opinions of knowledgeable professionals involved in the emergency care of nursing home (NH) residents. DESIGN Structured focus group interviews. PARTICIPANTS Five provider categories, including NH staff, NH physicians and nurse practitioners, emergency medical services (EMS) providers, emergency department (ED) nurses, and ED physicians. SETTING Two NHs, 2 […]
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OBJECTIVE To obtain opinions of knowledgeable professionals involved in the emergency care of nursing home (NH) residents. DESIGN Structured focus group interviews. PARTICIPANTS Five provider categories, including NH staff, NH physicians and nurse practitioners, emergency medical services (EMS) providers, emergency department (ED) nurses, and ED physicians. SETTING Two NHs, 2 EDs, and a county-wide EMS system. ANALYSIS Audiotaped discussions were transcribed and analyzed independently by 2 authors. RESULTS Themes included barriers to providing high-quality care, data needed when residents are transported in both directions between EDs and NHs, and possible solutions to improve care. Communication problems were the most frequently cited barrier to providing care. Residents are often transported in both directions without any written documentation; however, even when communication does occur, it is often not in a mode that is useable by the receiving provider. ED personnel need a small amount of organized, written information. When residents are released from the ED, NH personnel need a verbal report from ED nurses as well as written documentation. All groups were optimistic that communication can be improved. Ideas included use of (1) fax machines or audiotape cassette recorders to exchange information, (2) an emergency form in residents’ charts that contains predocumented information with an area to write in the reason for transfer, and (3) brief NH-to-ED and ED-to-NH transfer forms that are accepted and used by local NHs and EDs. CONCLUSION The transitional care of NH residents is laden with problems but has solutions that deserve additional development and investigation. KEYWORDS: Nursing homes, emergency service, hospital, emergency medical services, patient transfer
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http://www.jamda.com/article/S1525-8610(06)00174-5/abstract

August 7, 2019

Role of pharmacist counseling in preventing adverse drug events after hospitalization

BACKGROUND Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of […]
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BACKGROUND Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. METHODS We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs. RESULTS Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. CONCLUSIONS Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.
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http://archinte.ama-assn.org/cgi/content/abstract/166/5/565

August 7, 2019

Health Care Transition Initiative at the University of Florida

The mission of the Health Care Transition Initiative at the University of Florida is to increase awareness of, gain knowledge about, and promote cooperative efforts to improve the process transitioning from child-centered (pediatric) to adult oriented health care. Our vision is to improve the transition process for all adolescents and […]
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The mission of the Health Care Transition Initiative at the University of Florida is to increase awareness of, gain knowledge about, and promote cooperative efforts to improve the process transitioning from child-centered (pediatric) to adult oriented health care. Our vision is to improve the transition process for all adolescents and young adults, although our current efforts focus on those with disabilities and special health care needs.
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http://hctransitions.ichp.ufl.edu/