Diabetes services for adolescents and young adults – transition and beyond

Summary

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.

Challenge

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.

Objectives

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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QiC Diabetes Commended 2016
Patient Care Pathway – Children, Young People and Emerging Adults
Diabetes services for adolescents and young adults – transition and beyond
by ENHIDE (East and North Herts Institute of Diabetes and Endocrinology) – East and North Herts NHS Trust

Contacts

Dr A K M Raffles

Job title:
Consultant Paediatrician – Lead for C&YP Diabetes Services
Place of work:
East and North Herts NHS Trust
Telephone:
01438286318
Email:
andy.raffles@nhs.net

Resources

NPDAENH14-15.pdf - 333.3 KB

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