ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Endocrine Abstracts (2019) 66 OC8.4 | DOI: 10.1530/endoabs.66.OC8.4

Optimising transition care in endocrinology: an example of patient-focused quality improvement

Taffy Makaya1, Aparna Pal2, Gemma Anderson2, Helen Loo2 & Muhammad Masood Ashraf2


1Oxford Children’s Hospital, Oxford, UK; 2Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK


Introduction: The importance of good transition care has been highlighted by NICE and NHSI. Over the last 5 year we have focused on transforming our endocrine transition service.

Background: Our centre took part in the BSPED/BES-led 2014 National Adolescent Care and Transition Audit of Young people with Hormone Conditions. From this we identified key areas for service improvement including: families wanted to establish a better relationship with and have more confidence in staff looking after their children; wanting more information/support around transition processes and about their condition, allowing them to feel more empowered.

Methods: We worked on the following:

• Named Paediatric, and Adult Consultant; named Adult Endocrine Nurse for the transition Clinic.

• Engaged managers from adult/paediatric service teams; members of the Children’s Network Transition Working Group, to facilitate changes in job plans, IT processes, and implementation of the Ready Steady Go (RSG) programme.

• Worked closely with a pharmaceutical company which was piloting a Structured Endocrine Transition project, providing facilitation support to align our service with the NICE guidance on transition care.

•   Involved parents/patients in drafting a standard operating procedure (SOP).

•   Follow-on service evaluation 5 years after the initial BSPED/BES audit.

Outcomes: • A SOP has been agreed with critical input from families.

• From January 2016 we transformed the transition clinic from a single handover appointment to a longitudinal clinic, seeing patients 2–3 times in a joint adult-paediatric consultation; with marked improvement in care outcomes:

• All patients now complete a RSG questionnaire which is discussed during clinic; appropriate condition-specific patient information leaflets and signposting information are provided.

• Patient and family satisfaction (n=21):

∘ ‘happy with the care I receive from the transition service’=95%

∘ ‘treated well by the people who see me’=90%

May 2013-December 2015 (2.5 years): One handover clinicJanuary 2016–June 2018 (2.5 years): Longitudinal clinic
Clinics/year46
Total clinics1015
Total number patients seen4169
Lost to adult follow-up10%3%
Referrals to adults seen ≤6 months42%81%

Conclusions: Through extended collaborative working we transformed our endocrine transition service into a results driven, patient-centred service, with excellent outcomes.

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