IMPROVING ENGAGEMENT AND TRANSITION IN YOUTH WITH T1DM.

1
IMPROVING ENGAGEMENT AND TRANSITION IN YOUTH WITH
T1DM.

• Dr Nick Woolfield,
• Child and Adolescent Physician,
• Caboolture Hospital and North Lakes Diabetes
  Clinics, Metro North HSD,
• Queensland Australia 4510.
• November 2011.

2
Acknowledgements

• Diabetes Care team
• Janice Kerrigan
• Robyn Mallett
• Julie Tasker
• Annette Keid
• Maria Lyall
• Stella Wake
• Nina Haynes
• Dr Vern Heazlewood

3
Disclosures

• Am recipient of Novo Nordisk competitive grant.
• Speakers bureau for Novo Nordisk and Eli Lilly.

4
Demographics

• Population now around 350,000.
• Rapid population growth, both numbers of people
  moving in plus younger population.
• 29.7 population Caboolture Shire under 18 years
  of age.
• T1DM 120 150 patients under 20 years.
• Spread across two clinics.

5
Demographics

• About half under 13 years.
• About half over 13 years up to 20 years.
• One clinic hospital based.
• One clinic Health Precinct at large shopping
  centre (North Lakes).

6
TransitionJAH 199314570-576

• Smooth transfer of care at appropriate time from
  one care giver to another.
• Purposeful planned movement from child-centred to
  adult oriented health care systems.
• Optimal goal
• Uninterrupted health care
• Coordinated
• Developmentally appropriate
• Psychosocially sound
• Comprehensive

7
Transition

• Issues since 1993.
• Numbers of children with chronic conditions has
  increased. (90 survive to adulthood).
• Social changes evident
• Emerging adulthood (Arnett 2000) Concept of AYA.
• Children are staying longer at home, are studying
  longer and often do not have independence til
  later in life.
• Frontal lobe maturation complete by about 25 yrs
  (Giedd 2004)

8
Changes in approach to diabetes care.

• 1980s 1990s insulins were less than ideal
  NPH/Actrapid regimens common.
• Care with these could lead to good care.
• Regimentation was common.
• DCCT trial done in this era.
• Late 1990s
• Glargine, detemir, aspart, lispro plus others
• CSII

9
What has this meant.

• Basal bolus considered norm.
• CSII more widely available in most places.
• More flexibility with safety and control
  possible.
• Greater options for patients.
• Risks of hypoglycaemia now lower and risk of
  hyperglycaemia now considered much greater.
• Better control achievable.

10
Other issues surrounding transition

• Specific guidelines in specific places.
• At 18 years children must leave Childrens
  facilities and go to adult care.
• Geographical issues.
• Clinician issues.
• Some paeds like to keep their patients.
• Some adult clinicians do not like AYA.
• Patient issues.

11
Tools for assisting transition

• www.sweet.org.au
• Developed locally and gives guide as to what
  might be done in order to successfully move
  adolescents to adult care services.
• Good resource.

12
Readiness for transition.Schwartz et al (2011)
Childcare, health and development,37,6883-895

• SMART construct
• Pre existing factors
• Access insurance.
• Health status.
• Neurocognition/IQ.
• Inter-related components
• Development of patient.
• Knowledge base.
• Skills /efficacy.
• Beliefs expectations.

13
Readiness for transition.

• Goals
• Facilitating autonomy.
• Relationships
• Among patients, parents and providers.
• Psychosocial functioning
• Family functioning.
• Crisis management skills.
• Emotional issues relating to transition.

14
Readiness for transitionGilleland J et al J
Pediatri Psychol, 2011 Aug 29

• Readiness to Transition Questionnaire
• Adolescent kidney transplant recipients.
• Appears that there was good inter rater
  reliability.
• Need for identify components that would lead to
  improved transition readiness, adolescent
  responsibility and medical outcomes.

15
Realities

• Medical Maturity vs Maturity implied by age.
• Challenges
• Insurance
• Education
• Medical.
• Recreational.
• Transportation.
• Equipment.
• Pharmacy.
• ..

16
Measuring transition readiness of youth
TRAQSawicki et al J Pediatr Psychology 201136,
2, 160 - 171

• Transition Readiness Assessment Questionnaire.
• Two domains with high consistency.
• Skills for self management.
• Older age and activity limiting condition lead to
  higher levels.
• Skills for self advocacy.
• Female gender and activity limiting condition
  associated with higher levels of self advocacy.

17
What we do.

• Overall philosophy to promote self management.
• Four overall components
• After hours service support especially important
  for new pts.
• Electronic care plans for all at all clinics
  updated on line.
• Educational books re education offered for
  adolescents diagnosed pre adolescent years.
• Motivational interviewing component to service
  key to engage and maintain engagement.

18
Other components

• Same locations for patients, just different
  office or different day and different Dr.
• Consistency with the staff at educator /
  administrative level.
• Some flexibility with after hours clinic visits.

19
(No Transcript)
20
E care plans

• Completed and updated at every contact.
• Saved on line.
• Accessible to all the paed and ED doctors plus
  diabetes staff with write facility for paeds and
  diabetes staff.
• Sent to GP and given to patient at every visit.
• Allows for updates and changes without patient
  notes to hand.

21
Outcomes(Diabetes collaborative project)

• 50 patient review.(2011)
• 14.3 years
• Average HbA1c 9.2 .
• Averaging 4 bsl per day.
• 44 basal bolus, 22 pumps.
• Average drop with those who have gone through
  educational process 0.8 (20 patients).

22
Other data

• All engaged (loss to transition 0).
• Key issues that are being addressed
• Connected ENGAGEMENT
• Education
• Motivational interviewing key to promoting self
  efficacy with teens.

23
(No Transcript)
24
Motivational interviewing

• Autonomy vs authoritarian.
• Collaboration vs confrontation.
• Evocation vs Education

25
Summary

• Success at transitioning T1DM is crucial to long
  term outcomes.
• Developing a service that supports appropriate
  models of care that promote autonomy is
  important.
• Measuring readiness for transition should enable
  better and appropriate service development.
• Changes in relationships between paediatric and
  adult carers essential in addressing issues.

26
Summary

• Overcoming geographical and system barriers
  remains a major ongoing issue in most places.
• There are no proven strategies to achieve these
  goals Diabetes Care for Emerging Adults
  Recommendations for transition from Pediatric to
  Adult Diabetes Care Systems, ADA position paper
  A. Peters, L.Laffel Diabetes Care 2011, 34 2477
  2484,.

27
Thank-you

• Questions?