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