Incorporating the Six Core Elements of Health Care Transition Into a Medicaid Managed Care Plan: Lessons Learned From a Pilot Project

• The Six Core Elements were effectively customized for use in a Medicaid health plan.
• Completion of transition elements was high among plan's young adult pilot group.
• Most young adults were unprepared to manage their own care.
• Transfer of care was most difficult and required extensive care manager outreach.
• Starting transition planning before age 18 is essential.

This pediatric-to-adult health care transition pilot project describes the process and results of incorporating the “Six Core Elements of Health Care Transition (2.0)" into a Medicaid managed care plan with a group of 35 18–23 year olds who have chronic mental health, developmental, and complex medical conditions. The pilot project demonstrated an effective approach for customizing and delivering recommended transition services. At the start of the 18-month project, the Medicaid plan was at the basic level (1) of transition implementation of the Six Core Elements with no transition policy, member transition readiness assessment results, health care transition plans of care, updated medical summaries, transfer package for the adult-focused provider, and assurance of transfer completion and consumer feedback. At the conclusion of the pilot project, the plan scored at level 3 on each core element. The primary reason for not scoring at the highest level (4) was because the transition elements have not been incorporated into services for all enrollees within the plan. Future efforts in managed care will benefit from starting the transition process much earlier (ages 12–14), expanding the role of nurse care managers and participating pediatric and adult-focused clinicians in transition, and offering payment incentives to clinicians to implement the Six Core Elements of Health Care Transition.