
Healthcare Transition Services
College & Healthcare Transition
Executive function • Mental health continuity • Independent self-management (ages 16–25)
Program Overview
A structured, outcomes-driven program for ages 16–25 to prepare for the academic, medical, and psychosocial demands of college and early adulthood—grounded in guidance from AAP/Got Transition, AACAP, and ACHA.
Phased Care Pathway
- Phase 1 — Pre-Departure (6–8 wks): Readiness assessment, EF bootcamp, sleep plan (CBT-I if indicated), medication reconciliation, ADA/504 documentation, campus resources map.
- Phase 2 — Campus Launch (first 6–12 wks): Weekly/biweekly coaching for routines, task initiation, anxiety skills, roommate/problem-solving, safety/crisis plan, adherence checks.
- Phase 3 — Sustain & Optimize (ongoing): Monthly follow-ups, relapse prevention, academic check-ins, medication & sleep optimization, warm handoff to adult providers as needed.
Assessment & Outcomes Monitoring
- Screening/Baseline: PHQ-9, GAD-7, ASRS v1.1, C-SSRS, ISI, sleep diary; QbCheck® when ADHD is suspected.
- EF & Function: BDEFS short form; academic metrics (attendance, deadlines).
- Sleep Metrics: Efficiency, SOL, WASO, regularity index.
- Goals: 2–3 SMART targets per phase (e.g., 90% med adherence, consistent wake ±30 min).
- Reviews: Mini-reassessment every 4–6 weeks with plan adjustments.
Program Elements (Week-to-Week)
- Build a personalized routine (classes, study sprints, sleep window, meals, movement).
- Practice stress/anxiety skills (breath work, exposure scripts, test-day plans).
- Set up task systems (Calendar/Notion/LMS) with accountability nudges.
- Prepare letters & forms for ADA/504; rehearse requesting & using supports.
- Establish a medication/safety plan (refills, interactions, lockbox guidance).
- Implement a sleep protocol (CBT-I if indicated) to stabilize attention & mood.
Who Benefits
- Students with ADHD, anxiety, depression, autism, sleep disorders, or EF challenges.
- Teens moving from pediatric to adult care who need continuity & self-management.
- First-gen and underrepresented students seeking culturally responsive coaching.
Evidence & Guidelines We Follow
- AAP / Got Transition®: Six Core Elements of Health Care Transition.
- AACAP: Transition of care & college mental health parameters.
- ACHA: College health guidance on access, continuity, and collaboration.
- CBT-I: First-line for adolescent insomnia; strong evidence for daytime functioning.
- ADA/Section 504: Rights-based academic accommodations.
- NIMH / 988: Safety planning and crisis resources integrated into care.
Resources: Got Transition · AACAP · ACHA · NIMH · ADA National Network