Healthy and ready to work--Kentucky: incorporating transition into a state program for children with special health care needs.

Transition into the adult world for youth with special health care needs includes moving from pediatric to adult health care, from school to work, and from home to independent living. The federal Health Resources and Services Administration (HRSA)/Maternal and Child Health Bureau, through the Healthy and Ready to Work Initiative, has funded state demonstration projects. With this funding, the Kentucky Commission for Children with Special Health Care Needs in collaboration with Shriners Hospitals, families, and a variety of state and community agencies has been improving coordination of services and transition programming for youth with special needs. In their direct care and care coordination roles with youth and families, nurses focus on health promotion, health care and condition management, transition to adult care with funding, development of life skills, and opportunities for participation in the community. In their community outreach, nurses focus on collaborative planning, access to information, setting higher standards and expectations for services, documentation, and evaluation.