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UCSF Transition Program

CRISS

May 09, 2014

The Madison Clinic for Pediatric Diabetes at UCSF

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Goals of The Transition Program at Madison Clinic

provide youth with diabetes continuity of care

a seamless transition within our clinic to young

adult-trained provider

a successful transfer of care.

The new Madison Clinic at Mission Bay

School of Medicine

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Transition???

The Madison Clinic for Pediatric Diabetes

at UCSF

School of Medicine

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Transition ???


at UCSF

School of Medicine

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ADA: Challenges of Transition


at UCSF

• Lack of empirical evidence on best approaches

• Lack of well-defined criteria for readiness

• Changing social and demographic characteristics of

young adults

• Gaps in health insurance

• Differences in learning styles

• Lack of training for HCP in care of this age group

• No studies done in emerging adults with T2DM

• Emergence of chronic complications

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Transition Issues cont.


at UCSF

• Differences between health care delivery in the peds and adult setting

• Deterioration of glycemic control and other risk factors of the young adult

• Loss to follow-up• Increased risk for acute complications• Emergence of chronic complications• Psychosocial issues• Sexual and reproductive health issues• Alcohol, smoking and drug use

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at UCSF

Deterioration of glycemic control and other risk factors of the young adult

Poor control (SEARCH)• Only 32% of youth with T1DM age 13-18 meet ADA

HbA1c goal• Only 18% of youth over 19 meet ADA Hba1c goal

Loss to follow-up (increase morbidity/mortality)• BDA study showed that mortality among those with

T1D is 3X in men and 6X in women compared to peer group at ages 20-29 years old

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at UCSF

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at UCSF

• Increased risk for acute complications• Hypoglycemia

• DKA

• Emergence of chronic complications• Emergence of chronic complications

• T1DM : ~ 10 % of adol with mc-alb

• T2DM : ~ 30% of adol with mc-alb

• Discussion: What might be putting these emerging adults at risk for severe hypo and DKA?

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at UCSF

• Differences between health care delivery in the pediatrics and adult setting


• Loss to follow-up

• Increased risk for acute complications


• Psychosocial issues

• Sexual and reproductive health issues

• Alcohol, smoking and drug use

School of Medicine

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at UCSF

• Psychosocial issues• Feelings of guilt and anxiety about getting off track with

diabetes care• Worrying about the future and the possible complications• Depressive Symptoms• 18-20 y.o. 15-33% report depressive sxs• Emerging adults: 23-35% • > 20% of adolescent females (TODAY)• Eating Disorders• 2.4 x risk of developing ED in adolescent and post-adol

females• Associated with poor control, decreased adherence,

depression, increase DKA, increase microvascular comps• T2DM: 6% report binge eating and 20% reports subclinical

eating disorder

Diabetes Care for Emerging Adults: Recommendations for TransitionFrom Pediatric to Adult Diabetes Care Systems, Diabetes Care, November 2011

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SECTION HEADING


at UCSF

• Differences between health care delivery in the pedeatrics and adult setting


• Loss to follow-up

• Increased risk for acute complications


• Psychosocial issues


• Alcohol, smoking and drug use

School of Medicine

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at UCSF


– Fewer than 1 in 4 adolescent females aware of fetal and maternal risk of pregnancy**

• Alcohol, smoking and drug use– Alcohol and tobacco use similar to peers

• Alcohol increases risk of severe hypoglycemia

• Smoking increases CV risk and mc-alb

• Driving risk

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TRAiDTransition Readiness Assessment in Diabetes


at UCSF

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Demographics


at UCSF

Characteristics n=116Race % White/Caucasian 54.4% Black/African-American 6.1% Hispanic/Latino 23.7% Asian 7.9% Other 7.9%Age Mean (SD) Age (in years) 18.3 (2.7)Sex Percent Male 52.6% Female 47.4%Insurance Percent Private 48.6% Public 36.9% Unknown 14.4%

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Transition Discussion


at UCSF

I have discussed eventually transferring my care from a pediatric to adult provider

%

Yes, and we have a plan in place 11%

Yes, but we have no plan in place 38%

No 42%

I don’t know 8%

School of Medicine

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HbA1c profile for teens > 16 who took the TRAiD


at UCSF

Hemoglobin A1c (Age 16 and over)

Mean (SD)n=116

Overall 8.9 (1.8)Race White/Caucasian 8.7 (1.6) Black/African-American 9.8 (3.1) Hispanic/Latino 8.9 (1.8) Asian 9.3 (2.2) Other 9.3 (1.3)Insurance Status Private Insurance 8.2 (1.3) Public Insurance 10.0 (2.9)Age group Age 16-19 9.1 (1.8) Age 19-21 8.7 (1.5) Age >21 8.3 (1.9)

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Results: TRAiD


at UCSF

Transition Readiness Assessment in Diabetes

Responsesn=116

% Answering “No”

“I know what is required to stay on my health insurance.” 47.4%

“I have a plan for staying insured.” 53.6% “I know the difference between an adult endocrinologist and an adult primary care doctor”

37.4%

“I have discussed moving to an adult diabetes team with my family.” 57.3%

“I have discussed moving to an adult diabetes team with someone from my pediatric diabetes team.”

54.6%

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Results: TRAiD


at UCSF

Transition Readiness Assessment in Diabetes

Responsesn=116

Patient Autonomy Survey Questions % Answering “Yes”

“I know how to get in contact with someone from my diabetes team if I have questions.”

75.9%

“I am the person who contacts my diabetes team with questions or concerns.”

27.6%

“I use MyChart to contact my diabetes team.” 5.2%Parent Involvement Questions % Answering “No” “Does your parent/guardian observe you checking your blood sugar?”

31.2%

Transition Readiness Score1Mean (SD)

Score (range from 0-2) 0.8 (0.6)

1- Each patient’s “Transition Readiness Score” was created by averaging the responses for all questions answered listed in Table 1 under “Transition Readiness Survey Questions,” with “No” assigned a value of 0, “Sometimes” assigned a value of 1, and “Yes” assigned a value of 2.

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Implemented Transition Programs

• Climbing Wall + DM Education and Exercise

• Back to College Night

• Decoding Health Insurance

• Game Night

• Sex, Drugs & Rock and Roll

• Psychosocial groups

• Transition Day – Collaboration with JDRF, CHO, CarbDM, DYF

• Youth Advisory Board


at UCSF

Maureen McGrath, MS, PNP-BC, BC-ADMAssociate Clinical ProfessorCoordinator, Diabetes MinorUniversity of California, San FranciscoFamily Health Care Nursing

Marcela Arregui Reyes, MS, PMPTransition Coordinator, UCSF Benioff Children’s HospitalMadison Clinic for Pediatric Diabetes