Summary
Those who transitioned from paediatric to adult diabetes services at Isle of Wight NHS Trust were largely lost to follow-up and many found the whole process was intimidating. The healthcare professionals now work together as a multi-disciplinary team to ensure the transition is a smooth, planned, supported change process at an age-appropriate time. Joint transition clinics with the PDSN and adult DSN are provided throughout the year which allows the young adult transitioning through to adult services to meet the DSN to discuss any issues or concerns they may have regarding transition. The young adult is communicated with as an equal and information is shared to enable an informed decision. Six months following transition young adults are invited to meet the consultant in a joint clinic with the DSN. Since this process began in 2010, 94% of young adults have successfully transitioned.
Results
Patient experience reports high satisfaction on being treated as an adult, age appropriate advice and a more Transition is now an individual appointment with the PDSN and adult DSN to agree if the timing is right for the person to transition. Ninety four percent of people have successfully engaged at transition and there has been an increased attendance rate to adult services post transition.
Challenge
The transition service used to take the form of one appointment with the paediatric team and adult clinicians at a time dictated by age (usually 16-18 years) rather than by what the young adult themselves wanted. There was very little input from patients into the service design, and the meeting was held in a room which was rather intimidating. In short, it felt like an interview panel.
Objectives
To improve the transition experience so that the young adult became engaged with adult services and that this continued in the long term. Change the transition appointments and process to make the process more user friendly.
Solution
It was agreed that rather than meeting the whole team the individual should just meet the adult DSN, the dedicated facilitator, in the paediatric DSN clinic and discuss if transition was still appropriate. When the young adults meet the adult DSN for the first time they have an opportunity to ask questions about the service and what will happen. The idea is to make the whole process as non-threatening as possible and so that the young adult is in the driving seat but given information to make their own decisions whilst still having the support of a team. Education is also delivered on a one to one basis but also is available in groups depending on their choice. The main issues which are discussed are alcohol, recreational drugs, sick day rules, prevention of DKA and hypoglycaemia and driving and these are all discussed in a non-judgemental way. This is critical not only in relation to these subjects but any part of living with diabetes. Otherwise individuals either dread coming or will not attend and so disengage. The main original aim was to just improve the person's experience of this service and keep as many young adults engaged, so attending, as possible. However because of the new approach, this has had other added benefits of improving diabetes control and engaging in other services as well.
Learnings
Attending clinic appointments enables young adults to feel supported in all areas of their insulin management. Young adults feel able to disclose and discuss issues, such as drugs and alcohol without fear of being judged, and therefore obtain safe accurate information relating to these issues and diabetes to keep them safe. Discussions on all aspects on life is also encouraged in clinic to provide a holistic approach to care as transition occurs when concurrent life changes are occurring and young adults report that this is extremely beneficial to discuss issues that are concerning them rather than focusing on HbA1c and diabetes management. The open communication has resulted in further benefits and an increase in successful selfcare and management. This has been particularly identified in the number of hospital admissions for diabetes emergencies and unplanned pregnancy in those people who have transitioned through in this model.
Evaluation
Attendance to the specialist service has improved as well as attendance to local screening programmes. It has shown improvements in HbA1c of 16mmol/mol (some of these are only six months post transfer). Rates are improving for ACR screening (87%) and are higher than the national average for England which has an ACR rate yearly of 56.7% in people with type 1 diabetes (National Diabetes Audit 2015). Lower limb assessment screening rate is comparable to the rest of the country for all adults. This could still be seen as a success given the age group and the fact that they may assess their feet on a daily basis themselves and so may not acknowledge the need for official screening.
