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Transitional Care for Diabetics: Preparing Young adults for

A Lifetime

Lindsay O’Hara

Delaware Technical Community College

Nur 340- Nursing Research

Dr. Sokola

October 4, 2018
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Adolescence and young adulthood are filled with lots exciting and new events such

attending prom, graduating high school and learning to drive. There are also new responsibilities

these young adults face as they leave the comfort of their parents’ home. Becoming responsible

for themselves is a bigger task than most young adults realize. Managing a chronic lifetime

disease such as diabetes, only makes this time in a young adult’s life that much harder. More

and more, health care is seeing young adults being hospitalized with diabetic complications such

as diabetic ketoacidosis from non-compliance and poor health management. “Consequently,

emerging adults with T1D are at risk for adverse health outcomes, including: acute diabetes

complications, such as ketoacidosis and severe hypoglycemia; chronic microvascular

complications, such as nephropathy and retinopathy; and early mortality” (Garvey, et al., 2014).

Health care professional have insisted on putting into place better transitional care for these

emerging adults in order to prevent these complications, and keep compliance. The transition

process has many obstacles, but with fine tuning, can result in lowered glycemic values and

lowered hospital occurrences. It is important to help this vulnerable population manage their

lifelong disease, and establish a well-balanced medical routine early, in order to avoid multiple

hospitalizations and poor compliance later into adulthood.

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Statement of Problem

The increased risk of diabetic complications may experience from non-compliance and

lack of medical care, this vulnerable population needs help and guidance when transitioning from

pediatric care into the adult care system. They must assume responsibility for blood glucose

monitoring, medication administration, and making appointments for follow ups. Without proper

transition, the adverse outcomes begin to add up. With the proper transition tools and guidance,

is it possible that it will lead to less hospitalizations for young adults with diabetes? More and

more, I see young adults hospitalized with diabetic ketoacidosis. These patients are non-

compliant and often are not able to tell me when the last check their blood sugar or what are

normal blood sugar should be. Upon admission, my facility screens for diabetes. I ask several

questions related to diabetes such as “Do you know what a normal blood sugar level is?” and

“Do you know what do you if your blood sugar is too high/low?” 8 out 10 young patients are not

able to answers these questions. I feel like as nurses it is our job to help educate our patients and

give them the resources to successfully manage their disease once they are discharged. If these

young adults are unable to manage their chronic disease, we will see an increase in

hospitalization and possibly an increase in mortality.

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Literature Review

Transition Clinic

A recurring theme in my research showed that health care providers have relied on that

has shown improvement in glycemic levels is a pediatric to adult care transition clinic in order to

facilitate a smooth transition. The clinics are established in order to prevent any gaps in medical

coverage and to introduce young adults to new providers. During one study at the University of

Pennsylvania, hemoglobin A1C levels decreased from 9.7 to 9.0 after 6 months of attendance at

a clinic. One of the main concerns is the gap in coverage that this population seems to

experience. The same study from above showed that about a quarter of the referred participants

were unreachable. “Of the 122 referrals, 30 participants (24.6%) did not complete the transfer

and were not able to be contacted by either the adult or pediatric teams after referral was made”

(Agarwal, et al., 2016). These clinics have been proven to bridge the gap and improve the health

of the young adults willing to attend. It has been proven that structured transition using a clinic

produces better results in attendance and reduction in A1C level than unstructured transition. “At

3 years: ↑ clinic attendance in IG compared with CG (P < 0.05)” (O’Hara, et al., 2016). The

structured transition clinic also showed a decreased in diabetic ketoacidosis admissions. “↓

Diabetic ketoacidosis admissions (P < 0.05) and ↓ diabetic ketoacidosis re‐admission length of

stay (P= 0.02) after structured transition” (O’Hara, et al., 2016).

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Coordination of Care

Another theme that was seen throughout most of my research was the need for

coordination of care between the pediatric and adult settings. It is important to have care

coordination between the pediatric care and the proposed adult care. “Transition programs that

have implemented care coordination components have demonstrated success in retention of

participants” (Agarwal, et al., 2016). During a qualitative study that gave participants a chance to

express how they felt about the transition from pediatric to adult care. “In addition, various ideas

for overlapping visits with the pediatric team and a specific adult diabetes provider were

proposed. Seamless information-sharing was one commonly noted purpose for coordination

between pediatric and adult providers” (Hilliard et al., 2013). Coordination between the two

providers would help ensure accurate patient history, medication reconciliation and current

regimens.

Psychosocial Monitoring

This population is particularly at an increased risk for co morbidities such as depression,

substance abuse and eating disorders. It is important that patient have access to professionals,

peer and support groups to help manage these ailments. A qualitative study was performed using

open ended questions surveying endocrinologists, and they were asked how they felt about

transitional care, and about 30% of the sample expressed concern about psychosocial monitoring.

“Similarly, for the mental health scenarios, 30% of endocrinologists endorsed lack of expertise

as a barrier for substance and eating disorder cases (both 30%), followed by developmental

disability (24%) and depression (15%), in contrast to minimal expertise barriers (1–3%) for

recurrent ketoacidosis, obesity, and continuous glucose monitoring (Garvey et al., 2015). Many

young adults also expressed the need for peer support at the time of transition in order feel
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comradery. “Finally, patients felt that peer mentoring from other emerging adults who had

navigated the health care transition would be an invaluable source of support: I would have liked

to have had some kind of support system when I entered into adult care. I remember asking my

doctor, ‘are there any other college students that are doing this as well?’ [female, age 24]”

(Garvey et al., 2014). It’s paramount that these young adults feel like they have the support and

resources they need to help facilitate this difficult process.

Analysis

There were mixed methods used in all the research that I found. Mostly, qualitative

research was used because it’s important for researcher to understand the perception and

concerns of everyone involved in transitional care for diabetic patients, none more important

than the patient themselves. In order to improve upon the process, researchers need to hear from

the patients and use their suggestions to improve the process. Quantitative research was used in

order to evaluate if the transition process is helping by a reduction in hemoglobin A1C levels and

clinic attendance. I feel like the gaps in the research were minimal at best. One gap I did find

were qualitative responses from subjects that were post transition. After reading the studies, most

of the qualitative studies concluded it was hard to get hold of subjects after transition. Part of this

is due to the crazy schedule that a young adult has. All in all, the research I found all

recommended structured transition care with the use of a clinic was acceptable way to help

facilitate the needs of the population. The most important factor being the coordination of care

between the pediatric and adult providers.

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Recommendation

After thorough research, I would recommend a structured transitional clinic to facilitate

the needs of young adults with Type I diabetes. I would suggest the clinic have care coordinator

on staff in order to help the patients with finding outside resources such as a peer support group.

Registered nurses need to provide meticulous education in regards to glucose monitoring.

Perhaps some research into the use of text messaging in order to report glucose values to clinic

staff would be more convenient to this population, who already seem to have erratic schedules to

begin with. The more resources that are available to these young adults, I feel like we may be

able to reduce hospitalizations and complications.

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References

Argawal, S., Raymond, J., Schutta, M., Cardillo, S., Miller, V., and Long, J. (2017). An

Adult Health Care–Based Pediatric to Adult Transition Program for Emerging Adults

With Type 1 Diabetes. The Diabetes Educator, 43, 87-96.

https://doi.org/10.1177/014572171667709

Garvey, K.C., Beste, M., Luff, D., Atakov-Castillo, A., Wolpert, H., and Ritholz, M. (2014).

Experiences of health care transition voiced by young adults with type 1 diabetes: a

qualitative study. Adolescent Health, Medicine and Therapeutics, 5, 191-198

https://doi.org/10.2147/AHMT.S67943

Garvey, K.C., Telo, G., Needleman, J., Forbes, P., Finkelstein, J., and Laffel, L. (2016) Health

Care Transition in Young Adults With Type 1 Diabetes: Perspectives of Adult

Endocrinologists in the U.S. The Diabetes Educator, 39(2), 190-197

https://doi.org/10.2337/dc15-1775

Hilliard, M. E., Perlus, J. G., Clark, L. M., Haynie, D. L., Plotnick, L. P., Guttmann-Bauman, I.,

& Iannotti, R. J. (2014). Perspectives From Before and After the Pediatric to Adult Care

Transition: A Mixed-Methods Study in Type 1 Diabetes. Diabetes Care, 37(2), 346-354.

https://doi:10.2337/dc13-1346
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O’Hara, M.C., Hynes, L., O’Donnell, M., Nery, N., Byrne, M., Heller, S.R., and Dinneen, S.F.

(2016) A systematic review of interventions to improve outcomes for young adults with

Type 1 diabetes. Diabetic Medicine, 34, 753-769.

https://doi.org/10.1111/dme.13276