The CHF service model is innovative and characteristically different from those previously described in the literature that are primarily medicallybased. The clinic is based upon a model originally developed for educational settings but that was adapted for a health care setting using a family nurse practitioner in consultation with an interagency team of child and adult providers. A strength of this model is its use of available community resources to avoid service duplication and costs. Transition planning is an important role for pediatric nurses and pediatric nurse practitioners, as they possess the knowledge and understanding of living with a special health care need. Nurses can work with youth, young adults, families, pediatric and adult professionals, and service providers in assessing and identifying health care needs that affect the achievement of lifetime goals such as having the needed workplace accommodations or access to health insurance coverage. Youth-centered and asset-oriented plans developed in coordination with interagency partners will assist youth in achieving their goals for the future.