Introduction: Effective transition care is vital to empower young people (YP) to optimally self-manage their diabetes. National data highlights the concern regarding poorer care outcomes due to lower completion of annual care processes and higher rates of DKA whilst transitioning to adult care. The Children and Young Peoples Diabetes Team provides care for 170 YP aged 1619 years. In April 2017, 19% of this age group had a HbA1c <58 mmol/mol, significantly lower than the total clinic population of 29%.
Aim: To increase the percentage of 1619 year olds achieving a HbA1c of <58 mmol/mol by 10% each year commencing in September 2017.
Method: All multi-disciplinary team members were trained in Quality Improvement (QI) as part of a Trust wide Transition Transformation Programme. Process mapping of the transition model of care for 1619 year olds identified patient pathway improvements. The success of interventions was tested using Plan Do Study Act (PDSA) cycles. Interventions included; monthly HbA1C tracking, recruitment to structured education, employment of a Youth Worker, signposting to online resources, parent support sessions and development of an age-adjusted annual review proforma in conjunction with the Ready, Steady, Go programme for individualised care.
Results: In April 2018, the goal of 10% improvement in one year was met by 9 months, with 29% of YP achieving a HbA1c <58 mmol/mol. This transition improvement work continued during participation in the RCPCH National Diabetes QI programme from November 2018 to June 2019, and saw a further improvement to 37% achieving the aim.
Conclusion: The success of the interventions were due to the whole team adopting and implementing changes, despite the challenge of scheduling regular meetings to suit all team members. Review and tracking of real-time data allowed timely feedback of intervention effectiveness reinforcing the value of all team members efforts. Support of YP from a Youth Worker improved service engagement especially with structured education. Effective transition care is vital to empower YP to optimally manage their diabetes during this critical time. Further work is planned to develop a fully integrated diabetes service for 1925 year olds working closely with our adult diabetes colleagues.
27 - 29 Nov 2019
British Society for Paediatric Endocrinology and Diabetes