OR Journey Map Illustration

Team Oregon’s journey map illustrated by ConverSketch

Lead Organization

Oregon Center for Children and Youth with Special Health Needs (Title V)

Family/Youth Engagement Partner

Oregon Family-to-Family Health Information Center

Clinical Site

Doernbecher Children’s Hospital

Project Aims

  1. Collaborating with innovative partnerships to ensure medical home is available for young adults with medical complexity;
  2. Promoting shared plans of care (SPoC) as a tool to increase coordination of care among the young adult’s care providers;
  3. Incorporating shared decision-making among young adult, family, and providers in our SPoC approach; and,
  4. Preparing adult providers to serve as a medical home for young adults with medical complexity who are transitioning to adult care

Project Description

The CMC CoIIN Oregon Team established an intervention focused on preparing young adults with medical complexity (YAMC) for transition from their pediatrician to an adult primary care physician (PCP). The main objectives include (1) initiating a health care transition conversation between youth/family and pediatrician between ages 13-15, and (2) identifying a transition-focused goal for the youth/family to work on between appointments. Foreseeable outcomes from improving the transition from pediatric to adult care include increased quality of life, family well-being, cost-effectiveness, and better-shared plans of care between providers and families.

Focus Area(s)

  • Family engagement
  • Care coordination
  • Transition
  • Alternative payment methods