Pediatric Diabetes Transition Team

The Pediatric Diabetes Transition Team, Abbotsford Regional Hospital and Cancer Centre, developed a new model to successfully transition older youth to adult diabetes care.

Registered nurse Fay Hopkins knows her specialty – diabetes education – from the inside out. That’s because the Abbotsford Regional Hospital and Cancer Centre’s (ARHCC) Pediatric Diabetes Transition Team member not only started the pediatric outpatient clinic at the Abbotsford facility in 2008, but she also lives with type 1 diabetes.

“You don’t have to have this illness to connect with our patients, but I find it helps a lot for me,” said Fay, who was diagnosed at age 32. “You can’t get away from diabetes. It’s there 24/7, for life. Kids with diabetes get tired of having to deal with it, and I’m able to say, ‘I know what you’re going through, you’re not the only one, and it’s going to be okay.’”

It’s that level of empathy – shared by pediatric and adult diabetes clinic teams – that led them to take an innovative approach to ensure their patients were supported as they aged out of pediatric care.

The problem was that youth, especially those with complex conditions, clung to their pediatric providers long after they turned 18, feeling unprepared to move to the adult program. That’s because while the pediatric program provides close monitoring of the patient, the adult program emphasizes independence and self-management, which can be challenging for youth who may be dealing with other health and personal issues. So the pediatric clinic, which serves 180 clients at any one time, was reluctant to discharge 45 patients between the ages of 19 to 24 years old, although their caseload and wait-times for referrals grew.

“Historically, adolescent populations with chronic illness do abysmally when transitioning into the adult diabetes health care system,” said Luauna McCartney, manager of the adult diabetes clinic team at ARHCC. “Most transitioning adolescents have poor glycemic control or opt out of care altogether only to re-emerge later in the medical system with complications from mismanaged diabetes.”

To avoid that fate, the pediatric and adult care providers brainstormed, secured funding and joined together to create a Pediatric Diabetes Transition Team, consisting of Dr. Heywood Choi, Dr. Laura Stewart and Dr. Kenneth Anquist, nurses Fay Hopkins, Siobhan Whalley, Angela Johnston and Jaswant Mrar, dietitian Alima Soodeen, and unit clerks Theresa Jongema and Jane Hall.

Their goal was to develop a strategy for transferring patient care in way that was safe, medically effective and comfortable for the patient. They arranged for each patient to attend a series of three appointments shared between the pediatric and adult clinic locations and employees over nine months. The multidisciplinary team was up and running by March 2016, and to date has seamlessly transitioned nearly all of the older patients to the adult clinic.

“The teams went above and beyond by showing exceptional initiative, perseverance, accountability in managing these complex clients and commitment to ensuring that these patients did not fall through the gap in the system, said Abbotsford’s Pediatrics Manager Surjeet Melu. “Their commitment is extraordinary.”

As a result of the transition initiative, the pediatrics team has been able to lower waitlists back to the three month benchmark, and have received positive feedback from patients and their families.

The transition program has been so successful – and so few others in the field had developed anything close – that BC Children’s Hospital is researching the team’s approach to managing youth diabetes patient transitions as a best practice model of care.

“I’m really proud of the collaboration between the pediatric and the adult diabetes teams,” Fay shared. “Together, we’ve put in place a really patient-centred gradual change that makes it a little bit easier for our young patients to accept – and gives us time to say good bye.”

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