Matheny Medical and Educational Center is developing, with the cooperation of its acute care partners, a model to improve transitions to and from acute care hospitals for persons with multiple chronic conditions associated with developmental conditions such as cerebral palsy, spina bifida, Lesch-Nyhan disease and autism spectrum disorders. The project will incorporate the use of a nurse specifically dedicated to ensuring a smooth and effective transition among care settings, and the transmittal of important information about patient care needs via a “mini-medical record,” dubbed the “Transition Medical Record.”