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


The organization's internal review board approved the diabetes transition of care program as a quality improvement project. The interprofessional medical team for this project included pediatric and adult endocrinologists, a certified diabetes educator (CDE), a pediatric psychologist, a nurse project coordinator, and a pediatric dietician. Information technology experts built the transition data registry and developed an electronic version of the transition readiness questionnaire.

Measures Used to Collect Data

Transition Data Registry. A diabetes transition registry was created within the EMR to track the number of patients 14 years and older with Type 1 diabetes and their progress toward transferring to adult care. The registry sorted by diagnosis and recognition of diabetes on the problem list. Weekly chart audits were performed to confirm or reconcile the diagnosis of Type 1 diabetes in the patient's problem list. The CDE and endocrinologists were informed on how many and which patients needed transition readiness screening each week based on chart audits.

Additional information automatically collected for the registry included medical record number, name, date of birth, age, most recent transition readiness assessment questionnaire score, most recent HgAlc, last date of pediatric diabetes clinic visit, and comorbidities (e.g., depression, hypoglycemic unawareness), and insurance information. Adult diabetes clinic visits after transition were also automatically tracked in the registry for future long-term clinic attendance evaluation. This part of the registry was not pertinent for the pilot study, because no patients transitioned during the study period. The transition data registry automatically updated when new patients (e.g., new diagnosis or transfer from another organization) with Type 1 diabetes were seen in clinic.

Transition Readiness Assessment Questionnaire (TRAQ). The TRAQ tool (Figure) measures general transition readiness (i.e., not diabetes specific) and was administered as a youth self-report tool in this study. The TRAQ Flesh-Kincade reading grade level is 5.7, and it was available in English and Spanish versions (Sawicki et al., 2011). The TRAQ is a validated 20-item ordinal scale instrument with two domains, skills for self-management and advocacy (Sawicki et al., 2011; Wood et al., 2014). The questionnaire consists of five subscales: appointment keeping, tracking health issues, managing medications, talking with providers, and managing daily activities (Wood et al., 2014). Each question was evaluated with a 5-point Likert scale. A score of 80 verified that a patient participated in every aspect of the individual subscales, with a maximum score of 100 indicating that the patient was independently completing all necessary self-management and advocacy skills.


The Transition Readiness Assessment Questionnaire.

Patients completed the TRAQ tool during their routine clinic visits approximately every 3 months. The screening tool was administered and scored by the CDE in a face-to-face encounter. The CDE transferred written answers to the EMR for automatic scoring and to establish a permanent record for future assessment and evaluation of transition readiness. TRAQ scores were interpreted by the CDE and endocrinologist and were used clinically in two ways: (a) to help providers identify areas in which adolescents need more guidance and (b) to help providers determine when a patient is ready to transfer to adult services.