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IMPROVING ENGAGEMENT AND TRANSITION IN YOUTH WITH T1DM.

Acknowledgements. Diabetes Care teamJanice KerriganRobyn MallettJulie TaskerAnnette KeidMaria LyallStella WakeNina HaynesDr Vern Heazlewood. Disclosures. Am recipient of Novo Nordisk competitive grant.Speaker's bureau for Novo Nordisk and Eli Lilly.. Demographics. Population now around 350,

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IMPROVING ENGAGEMENT AND TRANSITION IN YOUTH WITH T1DM.

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    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. Transition JAH 1993:14:570-576 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) Child:care, health and development,37,6:883-895 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 transition Gilleland 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 TRAQ Sawicki et al J Pediatr Psychology 2011:36, 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.

    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.

    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?

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