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

Disclosures

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

In This Article

Discussion

Results

The low baseline mean TRAQ score (66.62) indicates that starting the transition process early in adolescence is critical. It can take several years for patients to gradually assume responsibility for comprehensive Type 1 diabetes management. Future studies can evaluate if improved TRAQ scores correlate with increasing age.

Of the five TRAQ categories, participants had lower baseline scores in the areas of appointment keeping and tracking health issues. This indicates that these two skill areas need more focused education with specific goal setting. Knowledge of health insurance and medical payments, under the appointment-keeping category, were also low scoring in research completed by Sawicki et al. (2011). Talking with providers was a strong skill area for patients in our study (mean score = 9.05/10) and parallels Sawicki et al.'s research. The mean score for managing daily activities, which includes skills such as meal preparation and use of neighborhood stores, was 12.19 out of 15. In the category of managing medications, patients had a mean score of 14.42 out of 20. These results indicate that patients feel confident in their medication management, but this does not correlate with the HgA1c mean level of 9.85%. The mean HgA1c level well above the ADA target of less than 7.5% for adolescents is a reminder that adolescence is a challenging time, especially for youth with Type 1 diabetes (Chiang, Kirkman, Laffel, & Peters, 2014). More emphasis on development of specific action goals targeting reduction of HgA1c level is necessary. A longitudinal study and larger sample size have the potential to show a correlation between higher a TRAQ score and a lower HgA1c level.

Limitations

There were multiple barriers to administering the TRAQ. Providers in the clinic decided that assessing transition readiness in newly diagnosed adolescents with Type 1 diabetes would be inappropriate. The optimal time to begin transition planning in adolescents with recent Type 1 diabetes diagnoses is unclear. Another barrier to TRAQ administration was patient complexity and their needs at the time of the appointment. For example, a patient changing from multiple daily injections to an insulin pump requires extensive education, and there is not time for transition planning.

There were limited opportunities to assess transition readiness at the offsite clinics because of work flow milieu and time constraints. Face-to face TRAQ data collection was avoided to reduce response bias by self-report, which could affect result validity (Newcomer & Triplett, 2010). The TRAQ Likert scale format was more time efficient when adolescents responded by self-report. An inherent limitation of the TRAQ is that it is a measurement of general transition readiness but is not diabetes specific. There are no specific, validated tools at this time to assess transition readiness in patients with Type 1 diabetes. Plans for eliminating TRAQ assessment barriers include electronic patient completion of the TRAQ to reduce transcription error and best practice alerts in the EMR to increase TRAQ administration consistency.

Organizations that do not partner as closely with adult diabetes centers may have added challenges with transition planning. Communication between pediatric and adult diabetes centers can be challenging without a shared EMR. This limitation can be diminished using free tool kits (Center for Health Care Transition Improvement Project Team, 2014), creating a data registry in the EMR, and potentially hiring a care coordinator.

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