Authors (including presenting author) :
LAM YH(1)(3), KWAN YWE(2)(3), LAU YFE(1)(3), CHAN KT(2)(3)
Affiliation :
(1)Department of Medicine,(2)Department of Paediatrics and Adolescent Medicine,(3)Pamela Youde Nethersole Eastern Hospital,Hong Kong
Introduction :
The transition from adolescent to adult care is fraught with challenges. Glycaemic control was affected by changed care model that required a comprehensive strategy from both the paediatric and adult team. Therefore, a team-based transitional care as a longitudinal integrated care plan along the clinical pathway to engage adolescent and to establish a trusted relationship is crucial to ensure continuity of care, improve patient journey and the treatment outcome. This provides the basis for the preparation and assessment of the knowledge and readiness of these adolescent and the provision of medical summaries and communication before the transfer. A dedicated Diabetes nurse as a coordinator plays an important role to fill up the service gaps exist in dealing with the challenges and coping for young diabetes transitional care.
Objectives :
To enhance diabetes self-care knowledge and preparedness for transition to adult care.
To empower self-advocacy skill in diabetes care.
To enhance compliance on the initial and subsequent follow up visits in adult clinic.
Methodology :
This is an ongoing program started since December 2015. Phase 1: Recruitment of Type 1 or Type 2 diabetic adolescent aged >16. Phase 2: Recruited patients receive a series of structured diabetes care education revision in Paediatric medical clinic to avoid extra attendance. Continuous education and assessment of diabetes self-care knowledge take place according to designed check list. Phase 3: Upon receiving referral and clinial summary from paediatric endocrinologist, diabetes nurse arranges first adult diabetes clinic, on a named doctor basis for at least one year to establish rapport. Phase 4: Outcomes including adult diabetes clinic attendance, HbA1c before and 12-month post program are evaluated.
Result & Outcome :
From December 2015 to December 2020, thirty-four eligible patients were recruited. Twenty-six patients were seen in the adult diabetes clinic. Eight patients aged< 18 remained in phase 2 education program. One defaulted the first adult clinic and re-attended after reminder. The default rate is low. The HbA1c level before and 12-month after transition to adult care were 7.35±2.22% and 7.40±1.90% (P-value:0.911) respectively. The continuous provision of a structured patient education, counselling and psychological support improves knowledge and confidence in self-care. This DM transitional care model proves to be smooth and important for successful transition.
