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• 1. Transition policy- process flow• 2. Transition readiness- patient’s chart reflects transition
information. Tailored specific plan • 3. Transition and transfer of care- “get acquainted appointments”,
education sessions, transition video, mentor program, materials
• 4. Monitoring/tracking- “Self-Care Assessment”, “Learning Needs Assessment” and “Transition Readiness Assessment”
• 5. Transition planning- Transfer form, patient’s face sheet, advance directive, patient checklist, chart contents, signed patient release, copy of insurance card- tour offered of FMLH
• 6. Transition completion- Patient meets 1:1 with multidisciplinary team at FMLH – final appointment with CHW (survey)
