Implementation of a Diabetes Transition of Care Program

Jeanne M. Little, DNP, CPNP-AC/PC; Janice A. Odiaga, DNP, CPNP-PC; Carla Z. Minutti, MD


J Pediatr Health Care. 2017;31(2):215-221. 

In This Article


Smooth transition of care for adolescents with Type 1 diabetes to adult-oriented health care is especially important because regular medical supervision is necessary to reduce the onset and progression of diabetes-related complications (Peters, Laffel, & The American Diabetes Association [ADA] Transitions Working Group, 2011). The boards of the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP)–American Society of Internal Medicine approved a consensus statement on health care transitions for young adults with special health care needs in 2002. This policy emphasizes the importance of providing high-quality, developmentally appropriate, and uninterrupted health care services to all youth transitioning to adulthood and provides general guidelines to support them during the transition. Nearly a decade later, a more detailed expert clinical report was published to outline best practice to transition youth to adult health settings (AAP, AAFP, and ACP, 2011). Transition planning is also a core indicator of adolescent and young adult health (Healthy People 2020, 2012).

The ADA has a position statement describing a framework for health care delivery during the transition period for adolescents with diabetes (Peters et al., 2011). The ADA provides best practice recommendations to transition adolescents, including beginning the process during the early adolescent years, gradual transfer of diabetes tasks from caregiver to adolescent, preparing youth to assume more responsibility for health care decisions and management (e.g., ensuring a proper amount of medication and supplies, scheduling appointments), thorough preparation for the differences in care in adult settings, and effective communication with the accepting provider (Peters et al., 2011).

The "Got transition" initiative is a national effort to provide transition resources to all adolescents, their families, and providers (Center for Health Care Transition Improvement Project Team, 2014). In particular, preparing youth with chronic health conditions for the eventual transition to adult-oriented health care requires individualized planning and ongoing skills development and acquisition.

Despite national recommendations for a transition standard of care, of the estimated 4.5 million youth in ages 12 to 18 years with special health care needs in the United States, only 40% are receiving the necessary preparation from health care teams to transition from pediatric to adult services (McManus et al., 2013). Currently, health care teams are working to increase adolescent transition–related skills, but most programs are not assessing patient transition readiness as a standard of care (McManus et al., 2013; Sawicki et al., 2011). Some transition challenges include limited research on best practice transition models, expectations by adult providers, absence of defined transition readiness criteria, psychosocial changes of adolescence, and deficient health care provider training to work with young adults (Peters et al., 2011).