The Madison Clinic for Pediatric Diabetes at UCSF - Criss

UCSF Transition Program The Madison Clinic for Pediatric Diabetes at UCSF

CRISS May 09, 2014

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.

School of Medicine

The new Madison Clinic at Mission Bay

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Transition???

The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF 3

Transition ???

The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF 4

ADA: Challenges of Transition • 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. • 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 The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF 6

Transition Issues cont. 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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The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF 8

Transition Issues cont. • 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? The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF 9

Transition Issues cont. • Differences between health care delivery in the pediatrics 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 The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF 10

Transition Issues cont. • Psychosocial issues • • •

•

The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF

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 Transition From Pediatric to Adult Diabetes Care Systems, Diabetes Care, November 2011 11

SECTION HEADING

Transition Issues cont. • Differences between health care delivery in the pedeatrics 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 The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF 12

Transition Issues cont. • Sexual and reproductive health issues – 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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TRAiD Transition Readiness Assessment in Diabetes

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Demographics

The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF

Characteristics Race White/Caucasian Black/African-American Hispanic/Latino Asian Other Age Age (in years) Sex Male Female Insurance Private Public Unknown

n=116 % 54.4% 6.1% 23.7% 7.9% 7.9% Mean (SD) 18.3 (2.7) Percent 52.6% 47.4% Percent 48.6% 36.9% 14.4% 15

Transition Discussion 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%

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HbA1c profile for teens > 16 who took the TRAiD

The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF

Hemoglobin A1c (Age 16 and over) Overall Race White/Caucasian Black/African-American Hispanic/Latino Asian Other Insurance Status Private Insurance Public Insurance Age group Age 16-19 Age 19-21 Age >21

Mean (SD) n=116 8.9 (1.8) 8.7 (1.6) 9.8 (3.1) 8.9 (1.8) 9.3 (2.2) 9.3 (1.3) 8.2 (1.3) 10.0 (2.9)

9.1 (1.8) 8.7 (1.5) 8.3 (1.9) 17

Results: TRAiD Transition Readiness Assessment in Diabetes

Responses n=116 % Answering “No”

“I know what is required to stay on my health insurance.” “I have a plan for staying insured.” “I know the difference between an adult endocrinologist and an adult primary care doctor”

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

The Madison Clinic for Pediatric School of Diabetes Medicine at UCSF

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

47.4% 53.6% 37.4%

57.3%

54.6%

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Results: TRAiD Transition Readiness Assessment in Diabetes Patient Autonomy Survey Questions “I know how to get in contact with someone from my diabetes team if I have questions.” “I am the person who contacts my diabetes team with questions or concerns.” “I use MyChart to contact my diabetes team.” Parent Involvement Questions “Does your parent/guardian observe you checking your blood sugar?” Transition Readiness Score1 Score (range from 0-2)

Responses n=116 % Answering “Yes” 75.9%

27.6% 5.2% % Answering “No” 31.2% Mean (SD) 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

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Marcela Arregui Reyes, MS, PMP Transition Coordinator, UCSF Benioff Children’s Hospital Madison Clinic for Pediatric Diabetes Maureen McGrath, MS, PNP-BC, BC-ADM Associate Clinical Professor Coordinator, Diabetes Minor University of California, San Francisco Family Health Care Nursing