Call for Applications: Pediatric/Adult Primary Care Healthcare Transfer of Care Quality Improvement Initiative

  • 13 Apr 2021

RIDOH, Tufts Health Plan, CTC-RI and PCMH Kids are pleased to offer pediatric and adult practices the opportunity to apply for funding to participate in the primary care “Health Care Transfer of Care” Quality Improvement Initiative”.  Family medicine practices are also welcome to apply, providing the practice is willing to partner and accept referrals from a pediatric practice.

Pediatric and adult primary care practice teams are invited to submit joint applications (Due April 30, 2021) with funding available for up to three teams with each dyad team consisting of a pediatric practice and an adult practice that apply for and complete the application together. This quality improvement initiative will provide a shared learning opportunity for pediatric and adult practices to work together to create an efficient and sustainable approach to assist youth and young adults to transfer from pediatric to adult care. The approach will be using the well-tested Got Transition’s Six Core Elements approach. Over the course of this 1-year pilot, practices will customize the content and process for transfer from the pediatric practice and integration to the adult practice. This process will be tested with a handful of youth/young adults, with or without special needs, who will actually transfer during the 1-year project.

Application Submission Process:

  • Each pediatric and adult practice team submits one completed application;
  • Each practice completes one cover letter indicating commitment and capacity for meeting project expectations detailed by April 30, 2021;
  • Each team submits one letter of support from the system of care by April 30, 2021, if team is from the same system of care. Practices that belong to two different systems of care submit a letter of support from each respective system of care.


  • Infrastructure Payments ($10,000 with $5,000 for the pediatric partner and $5,000 for the adult partner to offset costs associated with EMR modifications, staff time, and participation in quality improvement activities;
  • Monthly consultation from a trained clinical quality improvement facilitator;
  • Quarterly peer learning and best sharing from both pediatric and adult practices;
  • National technical assistance support (MCHB Got Transition Resource Center);
  • Use quality improvement strategies to optimize and standardize care for transferring young adults;
  • Inform healthcare systems of potential value-based payment approach for future transitions of care planning and implementation. 

Health Care Transfer of Care Improvement Initiative Objectives

Pediatric and adult team partners will work together to improve transition of care for youth as they transition from pediatric to adult care. Teams will be asked to test the transfer of care concept on a small sample of identified “transfer of care” young adults. The first 4 months will be “start-up” with customization of content and process followed by an 8-month pilot period for the 4-5 transferring patients, including a final pediatric visit, a joint communication telehealth visit with pediatric and adult primary care providers and transferring patient, and an initial adult visit.  Teams will apply selected Core Elements from Got Transition’s approach, using the performance improvement process, and develop and implement a more intentional and structured approach to the transfer of care process.

Timeline for Application/Selection Process





Call for Applications released

April 1, 2021


Conference call with interested parties to answer any questions.

Meeting ID: 745 041 0870

Passcode: 646876

One tap mobile: +13017158592,,7450410870#,,,,*646876#

April 9, 2021



Submit Letter of Intent (optional)

April 16, 2021


Submit application electronically to:

April 30, 2021


Notification will be sent to practices together with the Participative Agreement (inclusive of Health Care Transition Current Assessment tools)


May 7, 2021


Pediatric practice completes: Pediatric Current Assessment of Health Care Transitions Activity; and returns signed participative agreement;

Adult practice completes: Adult/Family Current Assessment of Health Care Transitions Activity; and returns signed participative agreement

May 14, 2021


Orientation Kick Off meeting for newly selected practices

May 19, 2021, 7:30-9:00AM


For additional application details, requirements, and timeline information, click here. Questions can be directed to Carolyn Karner at