Transitions of Care

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Best Practice Corner: PCMH Kids Health Care Transitions: 

Colleen Polselli and Deborah Golding from the Office of Special Needs/ Health Equity Institute at the RI Department of Health presented at the November Nurse Care Manager/Care Coordinator Best Practice Sharing Committee meeting. Their presentation* provided valuable information and resources for pediatric practices that are looking to provide support for adolescents and family members that are transitioning to adulthood. Information sharing during their presentation included recognizing the issues of transition, sample practice transition policies and resources that practices can use to help prepare families and adolescents for successful transitions. The Department of Health has created and is maintaining a Medial Home Portal that practices can use to access information, resources and best practice recommendations to assist them with establishing a purposeful, planned transition processes ("Got Transitions"  Some of the resources discussed during the presentation that practices can use in their office settings include: Parent Brochure: "What Parents and Caregivers Need to Know", a Guide for Young Adults: "Graduate to Adulthood" and an Adolescent Checklist: "Ready? Set. Go!". There are also programs available for youth and families including "Youth Advisory Council" and Community Information Sessions. Pediatric practices are using their practice staff, including Care Coordinators, to assist adolescents and families to better ensure smooth care transitions. 

*For a copy of the presentation at the November Nurse Care Manager/Care Coordinator Best Practice Sharing Committee meeting, please email

Our Mission

The mission of the Care Transformation Collaborative is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations we serve.