Collaborative working between paediatric and adult diabetes
services remains fragmentary and successful transfer onto adult
diabetes services is the exception rather than the rule. However,
East and North Herts NHS Trust has evolved joint Child and
Adult Diabetes services from two under-resourced teams in separate acute Trusts (using
paper records and with poor coverage of care processes) to a unified model of transitional
care for young patients aged 16-19. The single Trust's diabetes information systems capture both outpatient
and emergency hospital activity. The evolution of this service has taken over 20 years of close
collaborative working and has demonstrably improved health outcomes into adulthood. A telehealth project
will utilise text and Skype technology and be led by a young persons' worker and diabetes specialist nurse
to enable an innovative out of clinic approach to supported care, working closely with primary care.
Care of adolescents and young adults with diabetes remains challenging for those supporting this
vulnerable, frequently disenfranchised group, and a national priority. Young people with diabetes
aged 16-30, and their families, experience many difficulties. These include poor capture of basic care
processes and adherence to standards of care, lack of access to psychological and nutritional support,
a lack of 'join up' between health, social service and education services and delays in provision of
services, therapy and equipment. There is patchiness in good practice, such as variable provision of
a key worker to help with coordination and navigation of the health, education and social care.
To provide integrated seamless care across sites. To create new processes for transfer
from transition to young adult services with consistency of adult consultant and DSN
personnel, and to enhance care of disengaged young people aged 16-30.
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