Medically Fragile Case Management Program

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Project Details

Natalia Sencion at the family picnic photo

Transition Worksheet

The Transition Worksheet was developed by partners to open dialogue. The tool helps guide a discussion regarding the student and assists in identifying who should be brought on to the team to support the student, family and staff. The worksheet provides a framework for understanding barriers that need to be addressed by the team as well as a timeline for completion.


In order to have enough time to address areas of need, transition planning should begin 6-9 months before actual transition occurs. This may be well before the scheduled IEP is due. This extra time is necessary to accommodate the needs of the student who is medically fragile. 

Project Outcomes

The medically fragile population continues to age and enter both public and private school systems.  Family and case manager advocacy has resulted in transitioning many technology-assisted children into neighborhood schools. Smooth transitions begin with meaningful, child centered dialog between parents, school staff and providers. Nurse Case Managers from MFCMP help facilitate these discussions.