ESPE Abstracts

Background: Diabetes mellitus (DM) is a chronic metabolic disorder requiring daily care to prevent both acute and chronic complications. Intensive support to facilitate coping and self-care skills is advocated. Healthcare providers are challenged to manage the transition of adolescents from paediatric to adult diabetes services.

Objective and hypotheses: While centres providing structured integrated paediatric and adult care seem optimal, many patients opt for ambulatory care in community-based medical practices. These patients are in need of transition programs to prevent discontinuities in specialized care.

Method: In collaboration with the governmental health service, we developed a transition program for adolescents with DM. A specialized outpatient transition nurse (TN) meets patients and their parents in the paediatric diabetes center and plans the transfer to regional specialized adult health care services. DM related issues are recorded in a specially developed ‘diabetes health passport’ used by the patient. The TN accompanies the patient through the transition process, providing anticipatory guidance, ongoing assessment of psychosocial issues and promotes self-care in collaboration with both paediatric and adult healthcare providers.

Results: 75 DM patients have successfully been transitioned from paediatric to adult care, 100% are followed by an adult diabetologist. 75% are followed in private practice, and 25% in the hospital setting. Continuity of care was provided by the TN who held between 2 and 30 annual visits per patient depending on individual needs. Patients and the parents alike report high satisfaction with the program. At least three hospital admissions related to decompensated diabetes have been avoided due to successful home management by the TN.

Conclusion: We report on the successful implementation of a structured program for adolescents with DM transitioning from paediatric to adult care. This process includes focus on providing patient-centered care to promote autonomy and individuation. Our systematic approach appears to provide a structure for ensuring continuity of care and effective transition.