Transition from Paediatric to
Adult Diabetes Care
A significant number of young people with diabetes are 'lost' to specialist medical follow-up each year. There is evidence that these young people then re-present in early adult life with diabetes-related complications due to poor diabetes control. These complications could have been avoided had they had continued surveillance by a specialist diabetes service.
A large number of these young people are believed to be 'lost' to diabetes specialist care during transfer from paediatric to adult care.
In 2006, Queensland Health provided funds to the Mater Children's Hospital to develop an effective state-wide model for transitioning young people with diabetes from paediatric to adult care. This model is now known as Sweet- The Diabetes Transition Program.
This program actively engages health professionals and young people to participate in the transition process with the aim of reducing the 'drop out' rate and improving health outcomes in young people with diabetes.
Best Practice Guidelines
As part of the transition model Best Practice Guidelines have been developed to provide a framework to assist health professionals deliver effective care during the transition period based on the individual needs of the young person and within the availability of current resources.
The guidelines are currently awaiting sign-off from Queensland Health. Once this occurs the guidelines will be printed and disseminated to health professional's through-out Queensland.
To view a 'draft' of these guidelines click here to download the document. If you would like to comment on the 'draft' guidelines you can by emailing eunice.lang@mater.org.au.
Transition Model
The concept of simply transferring a patient from paediatric to adult care in a single step at a point in time has been replaced with the concept of 'transition', emphasising the need for the change to be guided, educational and therapeutic rather than an administrative event.
The most useful definition for transition comes from the American Society for Adolescent Medicine, where it is described as:
'the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centred to adult-orientated health care systems'.
Key Elements of the Sweet Diabetes Transition Program
Include:
- Flexible Timing of Transfer
- Assignment of a Case Manager to each young person.
- A Preparation Period
- A Choice of Adult Provider
- A Coordinated Transfer
- Transfer to an Interested and Capable Adult Diabetes Service
For more information on the Transition model download a fact sheet.
Templates
A 'Transition Progress Sheet' has been developed for the patient record and is ready to be trialled in three Hospitals across Queensland.
This 'sheet' will allow staff to document the young person's progress through the Transition Program. It is expected to be released at the end of July, 2008.
Once the 'Transition Progress Sheet' is available it will be disseminated to all hospitals in the state.
A draft of the 'Transition Progress Sheet' is available by 'clicking' on the link Transition Progress Sheet
A 'Transfer Checklist' is also currently under development and will also be available at the end of July, 2008. This form will also be available on this website.
If you would like to comment on the 'draft' progress sheet you can by emailing eunice.lang@mater.org.au.
Diabetes Education
Diabetes education should be delivered in a patient-centered and age-appropriate manner (ISPAD, 2000). Education can be delivered either as individual teaching or in small groups. The following provides key education elements that need to be delivered during the transition process.
Reference/s
International Society for Pediatric and Adolescent Diabetes (ISPAD): Consensus Guidelines 2000. Medical Forum International, The Netherlands, 2000.
Best Practice Guidelines for the Management of Type 1 Diabetes in Children and Adolescents. Queensland Health, 2002
Stillman, J., Lang, E., Grieve, C., (2003) Paediatric and Adolescent Diabetes Education Manual, For Health Professionals. Queensland Health, Queensland Government Publication. Module 8
Complication Screening Guidelines
Type 1 Diabetes - When to Start Screening
Diabetes complication screening should commence in children and young people:
- when the pre-pubertal child has had diabetes for 5 years, or
- when a pubertal adolescent has had diabetes for 2 years
As Type1 diabetes is an autoimmune disorder there is a greater risk of developing other autoimmune disorders such as:
- Hypothyroidism
- Hyperthyroidism
- Coeliac Disease
Screening for these associated medical conditions should also occur and have been included as part of the complications screening guidelines.
Type 2 Diabetes - When to Start Screening
Complication screening in young people with Type 2 diabetes should commence at diagnosis and then performed regularly thereafter.
Developed for Health Professionals to screen young people with Type 1 & Type 2 diabetes for diabetes complications.
Young Person's Screening Tool
In 2006, Complication Screening Guidelines were developed for Parents of children and young people with diabetes and are suitable for use by young people. These guidelines have been disseminated to parents and young people with diabetes throughout Queensland.
For young people with Type 1 & Type 2 diabetes
Stillman, J., Lang, E., Grieve, C., (2003) Paediatric and Adolescent Diabetes Education Manual, For Health Professionals. Queensland Health, Queensland Government Publication. Module 5
Australasian Paediatric Endocrine Group for the Department of Health and Aging: Clinical Practice Guidelines: Type 1 diabetes in children and adolescents. National Health and Medical Research Council (NHMRC), Australian Government, March, 2005
Resources
Fact sheets and other resources for Health Professionals can be found in the Resources section of this website
The Role of the General Practitioner in Transition
Role of the General Practitioner in Diabetes Transition
There are two important roles for the general practitioner (GP) in the management of young people with diabetes:
- If the young person has continuing involvement with a diabetes clinic or diabetes specialist:
The general practitioner has an important role as a partner in the management of all young people with diabetes and should be the primary point of contact for day to day health issues such as minor intercurrent illnesses, injuries and other health surveillance
- If the young person has dropped out of specialist care:
The role of the general practitioner becomes quite different, even critical. In this circumstance, the GP's role is to:
- build a professional relationship with the young person in order to understand their life situation and
endeavour to find out why they dropped out of diabetes specialist care.
- make an assessment of their current diabetes control
- undertake an assessment for diabetes complications
- encourage the young person to resume contact with a specialist diabetes clinic or doctor
- provide continuing supplies of insulin and other medication
If no pre-existing relationship exists with the young person or the young person appears reluctant to re-engage with a diabetes service then, one should consider all presentations as an opportunistic chance to ensure complication screening is kept up-to-date.
No Local Adult Diabetes Service
Not all areas in Queensland have an adult diabetes service or clinic that the young person can be transitioned to. Though not ideal or best practice, it may be necessary for the young person’s General Practitioner (GP) to become the primary service provider. In this situation there must be periodic review (6-12 months) from a visiting diabetes specialty outreach service or by referring the young person annually for assessment to either a diabetes clinic or private diabetes specialist.
It is essential that complication screening be carried out regularly (refer to Complications Screening Tool in this section or the Resources section of the website).
Referral to Diabetes Specialty Service
Immediate referral to a diabetes specialty service should occur in any of the following situations:
- If there are any abnormal findings on the annual Diabetes Complication Screen
- If the HbA1c is > 9% on two or more occasions in one year
- If there is continued and significant weight loss
- BMI <18kg/m2 or >25kg/m2
- If the young person is experiencing difficulty adhering to the treatment regimen (or is non-compliant)
- If the young person is pregnant or is considering becoming pregnant
- If there has been an admission to hospital for a diabetes related conditions e.g. ketoacidosis, severe hypoglycaemia
- Diagnosis of co-existing diseases
- If there are any mental health issues
References
- Best Practice Guidelines for the Management of Type 1 Diabetes in Children and Adolescents. Queensland Health, 2002
- Silink M., Editor: APEG handbook on Childhood and Adolescent Diabetes: The Management of Insulin Dependent (Type 1) Diabetes Mellitus (IDDM). National Library of Australia Canberra; (1996); 48: 87-92.
- International Society for Pediatric and Adolescent Diabetes (ISPAD): Consensus Guidelines 2000. Medical Forum International, The Netherlands, 2000.
- Australasian Paediatric Endocrine Group for the Department of Health and Aging: Clinical Practice Guidelines: Type 1diabetes in children and adolescents. National Health and Medical Research Council (NHMRC), Australian Government, March, 2005
