Tips for Transitioning Diabetes Care in Teens
Managing adolescents with diabetes through the transition to adult care is challenging in terms of both the physical and psychosocial aspects of care. Authors of a recent literature review in the December Journal of Clinical Endocrinology and Metabolism identify barriers to successful transition and key points to consider when orchestrating this shift.
Main Barriers to Transition
"In our opinion, the main barriers to a seamless transition from pediatric to adult care are 1) not having a plan for the transition process, 2) starting the transition process too late, 3) not empowering the adolescent to have an active role in the transition process, and 4) fundamental differences between pediatric and adult clinics," said lead author Sarah Lyons, MD, Fellow in the Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.
Other factors that complicate this transitional stage include the hormonal changes associated with induction of insulin resistance and the emergence of diabetes-related complications, poor diabetes self-management skills, changes in social environment (eg, attending college, living independently, or working full time), risk taking behaviors, and comorbid psychological disorders, according to the authors.
"When you identify barriers to transitioning care, it helps us to think, 'how can we improve this process?'" commented Rubina Heptulla, MD, Chief, Division of Pediatric Endocrinology and Diabetes, The Children's Hospital at Montefiore, Bronx, NY. In her experience, pediatric patients often experience a discontinuity of care when they leave for college. "But they do return home for breaks and if they could keep the same provider for a while, it helps them from getting lost in the shuffle until they find an adult care provider," she said. Also, she said, it is helpful to receive care at a center that offers both pediatric and adult diabetes care in the same vicinity.
Tips for Easing the Transition to Adult Care
"An important part in the transition process is assessing the adolescent patient's knowledge and skills for independent diabetes management," said senior author Mark Sperling, MD, Professor of Pediatrics at the Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center. "One resource available for providers is The Endocrine Society's 'Provider Assessment of Patient Skill Set,'" he said.
"Another important aspect is discussion of continuity of care and risk for diabetes related complications," Dr. Sperling said. "This could be addressed while writing a clinical summary for the patient and adult provider. For a template, The Endocrine Society's website has a 'Clinical Summary' form. These recommendations take time, and therefore it is important to have a plan and start the transition process at least one year before the anticipated transfer to adult care," Dr. Sperling added.
Montefiore's Model for Transitioning Care
At Montefiore Medical Center, a monthly meeting is held to help develop a model for streamlining the transition process for all chronic pediatric conditions that begin in childhood. "What I find as a barrier is finding enough internists to show up to the meeting and engage them in the transition process," Dr. Heptulla said. She hopes that engaging internists will ready them for patients with chronic childhood disease who, for example, show up at their practice at age 25 with complications.
A model is evolving at Montefiore of having an adult nurse practitioner attend visits along with Dr. Heptulla and her colleagues starting when patients are about 15 years of age. "So once the patients are 21 years and older are ready to move on to adult care, they already have developed a bond with another provider," she explained.
Dr. Heptulla also hopes that the Affordable Care Act will help the transition process because patients who would have lost insurance benefits under their parents' plan are now able to continue coverage up to age 26.