Transition Planning for Students with Healthcare Needs

Transition Planning for Students with Healthcare Needs


Position Statement

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It is the position of the National Association of School Nurses (NASN) that healthcare transition (HCT) planning and implementation for all students with healthcare needs should be a well-coordinated process that occurs whenever a student moves into, through, or out of a school setting. The continuation of safe, quality, equitable care for all students with healthcare needs is essential for supporting positive health and academic outcomes, so that all students have equal opportunities to attain their full potential. As a vital member of the interprofessional school-based team, the registered professional school nurse (hereinafter referred to as school nurse) is ideally situated to provide expertise, leadership, and care coordination for students during HCT (NASN, 2022).


Planning and implementing HCT for students with healthcare needs sometimes refers only to the pediatric to adult transition beyond secondary school. Federal laws provide specific guidelines for transition planning for students with an Individualized Education Plans (or Program) (IEP) that support strategies for HCT beyond high school (U.S. Department of Education, 2017; Tracey et al., 2024). However, for the purpose of this position statement, HCT represents a coordinated set of activities that assists all students with healthcare needs to transition to and from school settings at any stage, whether temporary or long term. This may include such times such as when a student enters school, moves between schools, leaves the educational system, or progresses beyond secondary school to engage in post-secondary academic or employment pursuits. It also includes returning to school following intermittent or prolonged absences for health reasons. Intentional and community-based HCT strategies enable a continuous approach to achieving positive health and academic outcomes for students with health conditions. A growing body of research evidence has found that “a structured HCT process for youth with special healthcare needs can show improvements in adherence to care, disease-specific measures, quality of life, self-care skills, satisfaction with care, health care utilization, and HCT process of care” (Schmidt et al., 2020, p. 92).

HCT begins with a family-centered approach to the identification of the unique needs and strengths of the student, in collaboration with the student, family, educational team, healthcare professionals, the school nurse, and behavioral health and social services systems (National Academy for State Health Policy [NASHP], 2020). Key components of the HCT process include planning, transfer, and integration into the school setting for each student (Lestishock et al., 2020; Schmidt et al., 2020). The National Center for Health Care Transition (Got Transition) has developed detailed evidence-based models for the HCT process which may be integrated as appropriate for the developmental needs of the student (Got Transition, n.d.; White et al., 2020). HCT efforts focus on arranging accommodations and services to meet students’ health, academic, social, and emotional needs and supporting adjustment in the school setting (Selekman & Ness, 2019; NASN, 2022).

Care coordination and effective, culturally sensitive communication among members of the student’s HCT team are critical to working proactively with families to identify and develop a shared plan of care (NASHP, 2020). Continuity of care “should be seamless in nature and is improved with the implementation of communication tools (e.g., integrated health records)” (Cassidy et al., 2022, p. 6). For HCT, the school nurse is in a key position to oversee care coordination, a foundational principle of 21st century school nursing practice (NASN, 2016; NASN, 2020). School nurse-led care coordination is defined as “the oversight and alignment of multiple evidence-based components and interventions that support the health and well-being of students with chronic health conditions” (NASN, 2019, p. 4).

When appropriate, students should engage as active participants in the HCT plans for their health and learning. For adolescents with healthcare needs, HCT to adulthood health services involves helping them “to progressively manage their own health and effectively use health services” (McManus et al., 2023, p. 780). This involvement includes the development of self-management and decision-making skills to foster active participation in maintaining their own health to attain their goals for quality of life (NASHP, 2020; NASN, 2022).

When there is a school nurse at school all day every day, school nurses are well positioned to support the process of HCT. It is a matter of equity that each student with healthcare needs has school nursing support. School nurses provide specialized expertise, knowledge, and skills for HCT coordination and leadership that include the capacities to:

  • Interpret and communicate medical information as appropriate across systems and among key stakeholders
  • facilitate the implementation of individualized healthcare plans (IHP) and related HCT requirements
  • connect families with school and community resources to address student HCT needs
  • monitor and assess the impact of HCT plans on student health and academic outcomes
  • support a system of accountability for meeting family needs and quality measurement and improvement of outcomes
  • advocate for clear HCT school district policies and guidelines

HCT experiences impact students, families, and the health and education systems. Planning for timely and continuous HCT can prevent interruptions in student access to healthcare services and educational experiences. School nurses effectively support student transitions between healthcare and educational settings and beyond. The development and implementation of HCT shared plans of care are essential to fostering student health and academic success, as well as postsecondary endeavors.


Cassidy, M., Doucet, S., Luke, A., Goudreau, A., & MacNeill, L. (2022). Improving the transition from paediatric to adult healthcare: A scoping review on the recommendations of young adults with lived experience. BMJ Open, 12:e051314.

Got Transition (n.d.). Got transition (website). The National Alliance to Advance Adolescent Health.

Lestishock, L., Disabato, J., Moriarty Daley, A., Cuomo, C., Seeley, A., & Chouteau, W. (2020). NAPNAP position statement on supporting the transition from pediatric to adult-focused health care. Journal of Pediatric Health Care, 34, 390-394.

McManus, M., Schmidt, A., Ilango, S., & White, P. (2023). Quality measurement gaps in pediatric-to-adult health care transition in the United States: A framework to guide development of new measures. Journal of Adolescent Health, 72(5), 779-787.

National Academy for State Health Policy. (2020). National care coordination standards for children and youth with special health care needs.

National Association of School Nurses. (2022). School nursing: Scope and standards of practice (4th ed.). Authors.

National Association of School Nurses. (2020). Framework for 21st century school nursing practice™: Clarifications and updated definitions. NASN School Nurse, 35(4), 225-233. doi: 10.1177/1942602x209283

National Association of School Nurses. (2019). Translating strategies into actions to improve care coordination for students with chronic health conditions.

National Association of School Nurses. (2016). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-53. doi:10.1177/1942602x15618644

Schmidt, A., Ilango, S., McManus, M., Rogers, K., & White, P. (2020). Outcomes of pediatric to adult health care transition interventions: An updated systematic review. Journal of Pediatric Nursing, 51, 92-107.

Selekman, J. & Ness, M. (2019). Students with chronic conditions. In J. Selekman, R. Shannon, & C. Yonkaitis (Eds.), School nursing: A comprehensive text, (3rd ed., pp. 480-499). F.A. Davis Company.

Tracey, C., Antonetti, D., & Jaquays, J. (2024). Education law for children with disabilities: The Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 (Section 504). In C. Resha & V. Taliaferro (Eds.), Legal resource for school health services (pp 173-185). School

U.S. Department of Education. (2017). Sec. 300.43 transition services.

White, P., Schmidt, A., Shorr, J., Ilango, S., Beck, D., & McManus, M. (2020). Six core elements of health care transition™ 3.0. Got Transition, The National Alliance to Advance Adolescent Health.

Acknowledgment of Authors:
CWendy A. Doremus, DNP, RN
Gayle Black, BSN, RN
Lucinda Hill, DNP, RN, CPN, CNE

Adopted: January 2019
Revised: January 2024

Suggested citation: National Association of School Nurses. (2024). Transition planning for students with healthcare needs (Position Statement). Author.

All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.