Improving the transition service and transfer process in Leeds

Julie Cropper; Danielle Simpson; Faye Bishop; Darren Meade; Aoife Kelleher; Fiona Campbell; Mel Hill; Emma Smith; Rachel Forshaw; Emma Bell; Sarah Trentham; Habiba Hassan; Katrina Berwick; Ramzi Ajjan; Sam Pearson

doi:10.1530/endoabs.111.P100

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Endocrine Abstracts (2025) 111 P100 | DOI: 10.1530/endoabs.111.P100

BSPED2025 Poster Presentations Diabetes 5 (10 abstracts)

Improving the transition service and transfer process in Leeds

Julie Cropper ¹ , Danielle Simpson ² , Faye Bishop ^1,2 , Darren Meade ^1,2 , Aoife Kelleher ¹ , Fiona Campbell ¹ , Mel Hill ¹ , Emma Smith ¹ , Rachel Forshaw ¹ , Emma Bell ¹ , Sarah Trentham ¹ , Habiba Hassan ² , Katrina Berwick ² , Ramzi Ajjan ² & Sam Pearson ²

Author affiliations

¹Leeds Children and Young People’s Diabetes Team, Leeds, United Kingdom; ²Leeds Young Adult Diabetes Team, Leeds, United Kingdom

Introduction: There is a long-established transition service in Leeds with MDT including Youth Workers and Psychologists working across Transition and Young Adult (YA) clinics. However, we have only recently been able to employ a YA DSN and have YA doctor and nurse attendance at four Joint Transition clinics per month. We want to improve the service in consultation with the young people (YP).

Aims: The goal was to standardise and improve process of transition using feedback from young people. Paediatric and adult services worked together as one transition team with monthly meetings, 18+ case management and Seamless Diabetes Transition training. This allowed development of a standardised process with individualised care provided to reduce inequalities for all in our caseload.

Methods: Regular team meetings focused on standardising care, including improving language around transition and team education sessions. Feedback was obtained from YP about the transition process (patients both pre & post transfer) using a questionnaire and youth forum. Transition documentation was updated. Participation in Seamless Diabetes Transition training supported the team to work together to navigate challenges.

Results: Questionnaire feedback was generally positive but highlighted areas for improvement including lack of flexibility with clinic appointments and challenges with clinic attendance. Youth forum qualitative feedback included improving visual impact of transition documentation, structure of YA clinic and suggestions re peer support opportunities. The transition process has now been standardised with clear expectations for both staff and patients, outlined in the transition pathway documents. The focused transition quarter has been successful with a team approach to Ready Steady Go (burden on staff eased, no longer tick box exercise). We have developed QR code education resources facilitating increased use of age-appropriate Digibete resources.

Discussion: Progress has been challenging at times, with clinical priorities taking precedence. However the process to date has supported progress, improving cohesion across the CYP and YA teams to enhance the transition experience of all patients. Moving forward we plan to compare quantitative data (HbA1c, DNA rates) from 2024 to now, to implement suggested changes including evening clinics and peer support opportunities, while continuing to collaborate with YP attending the service.