Summary
Collaborative working between paediatric and adult diabetes services remains fragmentary and successful transfer onto adult diabetes services is the exception rather than the rule. However, East and North Herts NHS Trust has evolved joint Child and Adult Diabetes services from two under-resourced teams in separate acute Trusts (using paper records and with poor coverage of care processes) to a unified model of transitional care for young patients aged 16-19. The single Trust's diabetes information systems capture both outpatient and emergency hospital activity. The evolution of this service has taken over 20 years of close collaborative working and has demonstrably improved health outcomes into adulthood. A telehealth project will utilise text and Skype technology and be led by a young persons' worker and diabetes specialist nurse to enable an innovative out of clinic approach to supported care, working closely with primary care.
Results
Primary Outcome of HbA1c improved in all age groups especially 16-19 year olds. There was also better capture of data and improved care processes (NPDA and Peer review fi ndings), improved access to psychology and reduced DKA admission rates. There were 6 DKA admissions (in 6 cases) in 2014-15 and 11 in 2015-16 (in 11 cases) - lower than historical admission date and comparing favourably with the NPDA fi gures
Challenge
Care of adolescents and young adults with diabetes remains challenging for those supporting this vulnerable, frequently disenfranchised group, and a national priority. Young people with diabetes aged 16-30, and their families, experience many difficulties. These include poor capture of basic care processes and adherence to standards of care, lack of access to psychological and nutritional support, a lack of 'join up' between health, social service and education services and delays in provision of services, therapy and equipment. There is patchiness in good practice, such as variable provision of a key worker to help with coordination and navigation of the health, education and social care.
Objectives
To provide integrated seamless care across sites. To create new processes for transfer from transition to young adult services with consistency of adult consultant and DSN personnel, and to enhance care of disengaged young people aged 16-30.
Solution
A unitary team was created with senior clinical (medical, nursing, dietetic, and latterly psychology) and managerial representatives developing a strategy to improve care for this target group. Having recognised through audit and shared information that the transfer to adult services was a poorly implemented process, and that a significant number of previously well managed patients 'disappeared' at age 19 years, services were revised to create a transition (to adult service) clinic. Discharge to adult services at 19 years was renamed 'transfer' to newly-established dedicated young adult diabetes clinics, provided on three clinic sites.
Learnings
A 'lost to follow-up' audit revealed the need for a new approach: the CCG has commissioned a two-year pilot of a non-medical provided model of care by diabetes nurse and young adult worker using telemedicine to enable re-engagement of a significant number of the 250 identified disengaged young patients. More generally, staff have developed and used new skills to enhance care through transition into young adult services - including improvements in medical and psychological care, with wider use of open questioning during consultations from all team members. The diabetes best practice tariff (BPT) has enabled the appointment of two psychologists, and audits of the transition service and transfer of care to adult services has led the CCG to support a pilot telemedicine service. Collaboration between two 'tribes' - Paediatric and Adult - has broken down traditional barriers, and established a truly seamless service. The traditional skill mix of paediatric and adult diabetes specialist nurses working together has improved specialist care - in particular the use of complex insulin delivery and glucose monitoring systems.
Evaluation
As this is a continuing evolution of a service, and is part of the comprehensive children, young people and adult diabetes service it is not possible to specifically identify cost savings - or indeed additional expenses. The service is fully funded from BPT Tariff and through the separate CCG funding of the telemedicine pilot. Income generated from BPT has helped expand psychology, dietetic and specialist nursing posts. Infrastructure changes have enabled clinics to take place for those in further education or work at more convenient times. The transition pump service has also been enabled in this group, with an evolution of care from child, through transition to transfer to adult services now a reality. Currently 19% of those in transition use insulin pumps. By strategic goal sharing the service has adapted quickly to policy changes, for example adoption of updated NICE Guidelines, technological advances and the changing demographic of our patient groups.
