The TRAQ is meant to be used over time, iteratively, perhaps every 6 months, to monitor
the progress of youth in their development of self-management skills. The key is
to engage the youth, using a motivational interviewing approach to have them select
and work on the goals that interest or motivate them. Once they engage and see the
value of working on these skills (and their parents recognize the value as well),
often their progress in adopting and mastering the skills follows. We believe that
setting goals and working on the skills measured in the TRAQ generalize to other skills
as well, meaning that if the youth acquires skills in one area (e.g., filling a prescription),
they are more likely to also acquire other skills. It does not matter which skill
area one starts with—we ask the adolescent and parent which ones they are most motivated
to learn at that time.
When youth are consistently performing the skills measured in the four domains of
the TRAQ (scoring on average a 4.0 across the questions in each domain), it is a sign
they are ready to move on to adult healthcare. With these skills (as displayed by
scores of 4 or more consistently across the scale) in hand, they are more likely to
successfully transition to adult care because they know how to access and utilize
the healthcare system and well as manage their own medications or other health issues.
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Instructions
We recommend that the youth fill out the track independently, without the parents input. However, when the TRAQ is reviewed with the adolescent, then the parent’s input can be used to verify or even edit the scores reported. If the youth’s developmental level or reading level (the TRAQ is written at a 7th grade reading level) is too low to fill out the TRAQ, the parent can fill it out for the youth, or the clinic staff person can read it to the youth and ask them to respond with their level of performance for each skill. -
How to use the TRAQ in the Clinical Setting: Breaking Down the Flow Sheet
This questionnaire was designed with the time management of clinics in mind. The TRAQ is short enough to be given before the physician sees the patient but thorough enough to gather detailed information. Above is an algorithm that we us at ETSU Pediatrics to guide our transition program and the use of the TRAQ.
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Start
The start of the algorithm is in the upper left corner—the patient comes in for an initial assessment—usually during a well visit anytime during adolescence. Due to resource constraints, we start this at age 15, however, it could be started earlier.
• Give youth the handout, “10 Steps to a Successful Transition”
• It is good to ask the parent and youth to scan this brief document as it gives an overview of and milestones for transition
• The patient is given the TRAQ at this initial visit and instructed how to fill it out (read the top portion to the patient, go over meaning of the response categories). -
Go Over the TRAQ
When reviewing the results of the TRAQ, the staff person, transition coordinator, provider, or nurse may want to review some of the responses to confirm that they do represent the actual skill level as performed by the youth. Adolescents may overestimate or over-report their abilities or behaviors in relation to the TRAQ. The review can create a dialogue with the parent on how the youth can obtain these skills. Sometimes it may require the parent to recognize that they need to let go a bit and give the youth the opportunity to try (and fail…some) these skills. -
Coding Transition
The provider or transition coordinator (see description of role below) must add a transition diagnostic code (diagnosis: Z71.89) in the electronic health records following the initial encounter for counseling for transition from pediatric to an adult model of care. In doing so, they are able to determine who has and has not begun the process of healthcare transition. Frequency of using the TRAQ. We use this code to track people in the EMR and call them back for a TRAQ at least once per year if their TRAQ scores are less than 5 on average. If the youth has a condition that requires them to visit the clinic more frequently, a TRAQ will be given every six months to continually monitor the youth’s progress as well as review the goals they established. Using the transition diagnostic code can allow the provider to bill for the time used to counsel related to transition. For a document that goes over all strategies for coding and getting paid for doing transition counseling, see: McManus M, White P, et. al. 2021 Coding and Payment Tip Sheet for Transition from Pediatric to Adult Health Care. Got Transition. March, 2021. Click here! -
How to Grade the TRAQ
The TRAQ is divided into 4 sections, with two additional questions on confidence (self-efficacy) and importance (motivation):
· Managing Medications
· Appointment Keeping
· Tracking Health Issues
· Talking with Providers
These four sections are individually graded by on a scale of 1-5 (1 being “No, I do not know how” and 5 being “Yes, I always do this when I need to”) by finding the average. Following this, a total average is taken. The two questions in Importance and Confidence are individually graded on the 1-5 scale. To score the Questionnaire, we create an average score in each section. We do look across all 4 sections to look for patterns, such as an area that is the lowest or an area that has the highest scores.
Intervention Level is Based on Scores of the TRAQ
Those with total average scores of 1-2, 2-3, and 3-4 require transition education. The process of transition education requires four steps.- Educate on Self-Management skills—specific skills within each domain, starting with the domain that they choose, or perhaps the domain that they are lowest in
- Use Motivational interviewing to increase motivation and self-efficacy
- Go over the goals found in the “Transition Goals” section of this website. Explain to the youth how the categories of the goal align with the categories if the TRAQ and answer any questions they may have.
- Encourage them to select or choose 2-3 goals/activities in one or more areas to work
on. It should be what interests them. The skills do generalize, so committing to
one or more goals is more important that the actual goal chosen. Sometimes the goal
should be the one they need the most. For example, if they have to take birth control
pills regularly but are not consistent, perhaps working on a medication reminder goal
should be a high priority. The parent or caretaker can be brought in on the process,
using care to not alienate or disempower the adolescent and feed into social loafing
or parental over-control.
Intervention looks different for each level of TRAQ scores. These levels are 1-2, 2-3, 3-4, and 4-5. Below are examples of how the same conversation between a provider and patient might be altered depending on the youth’s TRAQ score. -
Example Prompts for TRAQ Score Levels
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1-2 (Not yet started doing these behaviors, may not be interested in starting to learn them)
Provider: John, we want you to be as independent and confident as possible when it comes to managing your health and healthcare. Tell me more about how you manage your health and healthcare.
John: Well, my mom fills my prescriptions and schedules my appointments, so I don’t have to worry about that until college.
Provider: Do you plan to go to college when you graduate from high school?
John: Yes, I do.
Provider: Great! We want you to know how to do these things and more before you go to college, so your mom doesn’t have to go to college with you (laugh!). Seriously, how do you think you could start doing these activities on your own? For example, have you tried doing this yet?
John: Well, I tried scheduling my own appointment, but I didn’t know where to start. Also, I don’t know how to go the pharmacy to get my prescriptions without my mom. Provider: How about if we took small steps? We have two videos that you could watch to show you how to do those two tasks, both making an appointment and getting your prescriptions. Could you start with that?
John: I could make a pretend call to the doctor’s office with my mom for practice and then schedule my next one. Also, I’ll go the pharmacy and try to get my prescriptions without my mom.
Provider: That sounds good! I like a great idea, John! Let’s set those two other goals together. -
2-3 (There is interest and perhaps some initiation of self-management behaviors)
Provider: John, we want you to be as independent and confident as possible when it comes to managing your health and healthcare. Tell me more about how you manage your health and healthcare.
John: I’ve ordered my own prescription and called the doctor once or twice.
Provider: Have you tried doing this regularly yet?
John: No, I only do it when my mom is busy.
Provider: How about if we took small steps? What steps would you like to take?
John: I could schedule my next appointment with you through Patient Portal and I could be more consistent in picking up my prescriptions before they run out.
Provider: That sounds like a great idea, John! Let’s set two other goals together. You might want to sign up for the CVS or Walgreens app. They’ll remind you of when a prescription is up for refill or when it is ready for pick up! (The provider goes into coaching mode when there is some initiation on the part of the patient). -
3-4 (There is interest, initiation and some active participation in the self-management behaviors)
Provider: John, we want you to be as independent and confident as possible when it comes to managing your health and healthcare. Tell me more about how you manage your health and healthcare.
John: Well, my mom sometimes fills my prescriptions and schedules my appointments, but I’ve been doing this some of the time.
Provider: Great! That is really important that you have started to take over these responsibilities. How can I help you with them? Do you have any questions?
John: I think I know how to do this stuff. I just need to do it myself. Mom can check on me, but I think I got this. But…I’m really not sure how I can keep my health insurance when I go to college. And I’m wondering where I will get care during college. I’m going off to Harvard in Boston.
Provider: Fantastic! Keep up the good work. I’ll check to see how these general activities are going next time. Yes, let’s talk about insurance and about getting care at college. (This would take the provider into a) giving information on how to keep insurance, depending upon their current health insurance and b) discussing a plan for how John can get care at college. -
4+ (The youth is doing, pretty consistently, most of the behaviors in the section)
Provider: John, we want you to be as independent and confident as possible when it comes to managing your health and healthcare. Tell me more about how you manage your health and healthcare.
John: Well, I usually fill my prescriptions and schedule my appointments, so my mom doesn’t have to worry about all that.
Provider: As a capable young man, we want you to know how to do these things and more before you go to college. Do you have a plan for managing all this in college?
John: You and my mom and preparing me now, so I feel confident that I’ll be able to manage my own health and healthcare by the time I’m in college.
Provider: Have you tried doing this regularly yet?
John: Yes, I have!
Provider: How can we continue your excellent progress? What steps would you like to take?
John: I can completely take over my prescriptions and appointments.
Provider: That sounds like a great idea, John! Let’s set two other goals together.
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Following Up
The transition coordinator or clinic staff will record a patient’s goals, TRAQ score, and any meaningful information gained from the transition education. They will then contact individuals requiring transition education by phone or Patient Portal to follow-up on goals set and answer questions the youth may have. Were their goals completed? Did they run into challenges? If they completed a goal, what new goal would they like to set?
Those with a score of 1-2 will be contacted at one-month intervals. Those with a score of 2-3 will be contacted at two-month intervals. Those with a score of 3-4 will be contacted at three-month intervals. Every six to twelve months, patients will be brought back into the clinic to assess their progress and retake the TRAQ. This can be done at either a designated transition appointment or a regular visit (e.g., a well visit or appointment for chronic conditions). -
Transition Education and Transition Needs
When a youth scores a 4-5 on the TRAQ, they no longer require transition education. In this instance, the provider and transition coordinator can begin transitioning the patient to an adult provider with an adult model of care. The provider and/or transition coordinator will establish connections with adult doctors to refer them to. By having many adult doctors, patients with a variety of insurance plans and medical conditions will be covered. If a patient will no longer have health insurance upon turning 18, they are directed to healthcare.gov to purchase insurance.
For youth with developmental disabilities, please refer to the page “Youth with Disabilities or on an IEP” for further information and resources. For youth entering college, it is important to establish a care plan. Will they travel home for healthcare visits or find a primary care provider in their college town? Does their college have a healthcare clinic on campus? For a checklist on basic healthcare management skills a college student would find beneficial to master beforehand, please visit our “College Healthcare Planning” section.
However, for patients staying local, an example of a low TRAQ, goals, and transition plan for those ready to move forward is below. Compare this and the different approach taken with the high scoring youth below to see these steps in action.
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Low Scoring TRAQ Example
With a total score of 2.4 and respective scores of 1.8, 1.25, 1.5, 3.8, 4.0, John is not ready to transition to adult care. When asked which areas he would like to work on based on his scores, John picks appointment keeping, his lowest scoring section. The transition coordinator agrees and tells John that is a great place to start. John decides to arrange for a ride to the doctor’s office two weeks in advance, watch a video on how to schedule appointments, and schedule his next appointment himself. John receives a transition follow-up phone call two months later. He has seen the video but has yet to schedule his appointment and arrange for a ride. By the time he comes in six months after last taking the TRAQ, John completes his goals. He retakes the TRAQ, is given a new score, and the transition education process continues.
However, those with a score between 4-5 do not need transition education or have completed transition education. These patients must be encouraged to continue to grow in self-management. Following this, two steps are taken to complete the transition process.
1. Finalize transition plan
2. Transition to adult care -
High Scoring TRAQ
Mary Jane comes in for a regular well child check. She is 18 years old and has been receiving transition education for two years. With a total score of 4.5 respective scores of 4.4, 4.5, 5.0, 4.2, 4.0, Mary is ready to begin transition to adult care. She is nervous about this change, but she knows that she is ready to manage her health and healthcare in an adult model of care. The transition coordinator has worked with her and understands that her conditions are well managed. However, Mary sees a pediatric cardiologist for a heart condition. Having a list of adult care specialists, the transition coordinator finds a cardiologist who takes Mary’s insurance. After making sure that Mary is ready and comfortable with transitioning to adult care, the transition coordinator lets Mary’s primary care physician know that she is ready for a referral to a cardiologist and a new primary care physician. After Mary has transitioned to adult care, the transition coordinator calls her to ensure a smooth and comfortable transition.
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Transition Coordinator
Ideally, transition is managed by a transition coordinator, however this process can be managed by sharing the responsibility between the nurse and provider. The transition coordinator can manage all of the above steps thoroughly discussed above. Having a transition coordinator in the clinic, patients are given more transition education, individual time, support for their transition plan, ensured access adult care providers and specialists, and guidance on maintaining insurance. In the case of intellectual disability, the transition coordinator assists with the SSI application, guardianship/supported decision making, and CHOICES/living plan if needed.
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References
Johnson K, Wood DL, McBee M, Reiss J, Livingood W. TRAQ Changes…Improving the Measurement of Transition Readiness by the Transition Readiness Assessment Questionnaire. J Pediatric Nursing. 2021;59:188-195.
Melanie A. Gold, DO, FAAP and Patricia K. Kokotailo, MD, MPH, FAA. Motivational Interviewing Strategies to Facilitate Adolescent Behavior Change. Adolescent Health Update, 2007
William Miller, PhD, Stephen Rollnick, PhD. Motivational Interviewing: Helping People Change, 3rd Edition (Applications of Motivational Interviewing) 3rd Edition. Gulliford Press, New York, NY. 2007.