Endocrine Abstracts

Background: Transition from paediatric to adult services represents a high-risk period for young adults (YA) with diabetes, often leading to disengagement and poor outcomes. Transition Safe and Sound (TraSS) is an NHS England-funded pilot designed to bridge this gap through a failsafe, multidisciplinary model.

Aim: To evaluate the clinical, psychosocial, and service-level impact of the TraSS model for YA aged 16 to 25 years.

Method: The pilot implemented a team including a failsafe officer, transition outreach specialist nurse, youth worker, dietician, psychologist and project manager. Integrated pathways were created (between paediatric and three adult services) to identify and support YA with recurrent non-attendance, high HbA1c, or classified as ’unable to contact’ (UtC). Referrals were triaged and patients underwent assessment by youth worker and/or transition outreach nurse and targeted further support provided. Validated standardised screening tools were used for psychological screening. Contact data, engagement, and outcomes were analysed.

Results: 211 patients were referred to the TraSS model. The primary reasons for referral included 35% for diabetes education, 21% for psychology support, 21% for youth worker support, 18% for high HbA1c support, 11%% were uncontactable, and 11% were non-attenders. Following assessment, 45% of contacts were provided by youth worker, 33% by Diabetes Specialist Nurse, 12% by multiple members, 10% by failsafe officer, psychologist, or dietitian. Of 24 patients on the UtC pathway, 83% were successfully contacted and 58% engaged with adult care. Psychological screening (n = 81) showed 65% reported moderate to severe diabetes distress; 28% reported severe distress and 12% showed disordered eating risk (including insulin omission). 36 peer group events involving 73 YA were delivered, including “Cook & Count” and psychosocial drop-in, with positive YA feedback. HbA1c levels (n = 76 paired samples) demonstrated a median reduction of 8.4 mmol/mol (and 5.8 mmol/mol, excluding newly diagnosed patients).

Conclusion: The TraSS model successfully supports young adults with diabetes, leading to improvements in both clinical outcomes (e.g. HbA1c) and psychosocial wellbeing. An integrated service enhanced continuity of care. Holistic, tailored, patient-centred support combined with psychological screening unveiled high levels of unmet emotional and psychosocial needs, underscoring the essential role of multi-disciplinary care during transition.