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 existing transition of care program for patients with Type 1 diabetes is a major building block for preparing all chronically ill adolescents cared for within the same health system for the shift to adult care. The transition data registry was found to be useful as an effective method to track adolescents with Type 1 diabetes and identify adolescents who had no encounters with the diabetes health team in 12 months. The development of the registry adds the ability to follow patient attendance in the adult diabetes clinic within the academic medical center to evaluate for gaps in care after transition.

A transition of care program was implemented to meet national standards of care to better prepare adolescents with Type 1 diabetes and their families for adult health services. The transition process can take up to 4 years and varies from patient to patient, reinforcing the need for transition plans that are gradual, individualized, family centered, and coordinated. Routinely assessing transition readiness beginning in early adolescence is essential to prepare youth for the increased self-management and self-advocacy skills they must obtain as they reach adulthood.