TRANSITION TO ADULT CARE

Transitioning from pediatric to adult care providers can be a vulnerable time for the patient and family. It may be extremely difficult to leave caretakers whom they have come to know and trust. Many providers are flexible and do not require all patients to transfer to adult care once they turn 18 in order to allow for a more gradual transition. Pediatric clinicians can help prepare an adolescent and family for differences they may encounter when they transition to adult care providers. For instance, the nurturing atmosphere characteristic of pediatric care in many instances may be replaced by a faster pace and less interaction time in adult services.

Clinicians working in adult diabetes management must likewise be aware that young people transitioning from pediatric services may require assistance and greater attention to integrate successfully into the practice. Clinicians in both pediatric and adult diabetes care can explore with the patient and family what barriers exist to the patient moving successfully into the adult setting. The diabetes management team can also work with the patient and family to develop goals and interventions to help ensure the patient’s ability both physically and psychologically to take responsibility for diabetes self-management.

The shift from pediatric to adult healthcare presents a high risk for loss of cohesion in the delivery of services and is a period when many young people no longer receive adequate health care. Others may never take ownership of their diabetes and remain over-reliant on their parents for diabetes management. This transition phase is linked with worsening glycemic stability, higher rates of acute complications, and the beginning of chronic complications associated with poor diabetes control (ADA, 2020a).

The clinician therefore advises parents to permit the adolescent to attend medical appointments alone during at least the last six to nine months of their pediatric care. This step fosters independence and allows the young person to practice describing their symptoms, answering provider questions, posing their own questions, and planning implementation steps that may result from the appointment. Initially, parents may not react well to this suggestion. In this case, the clinician can provide parents with a summary at the end of the appointment (Roemer, 2016; Ramchandani, 2019).

ANSWERING PARENT/PATIENT QUESTIONS

Q:How can young people become more independent in diabetes self-management before moving away from home?

A:Working with the diabetic management team to assist young people to take ownership of their diabetes self-management is important. Young people with diabetes should be assessed for their readiness to become independent in diabetes self-care, and any concerns need to be addressed. The most important areas to be considered are the young person’s level of diabetes knowledge, their ability to self-management insulin, and their nutrition and health behaviors.

Moving Away from Home

Young people moving away from their family home or leaving to attend college is often stressful and may introduce unique issues related to diabetes care.

Patients will have new providers involved in their care, and so a priority for the diabetes care team is to assist the young person and their family in locating new providers who have experience in managing diabetes (see above). For those attending college, the young adult and parents are encouraged to contact the college’s health center.

Insurance and financial considerations for healthcare coverage are an important issue. The Affordable Care Act allows for continued coverage under parents’ healthcare policies until the age of 26 years (ADA, 2020a). Parents are advised to contact the insurance provider in advance to learn how coverage may be affected if their child with diabetes moves to a different part of the state or out of state.

Adapting to college or work schedules, making new friends, and socializing can all push diabetes care into the background for the young adult. Parental supervision and the support of childhood friends may no longer be available. The diabetes care team therefore works to ensure that diabetes self-management remains a top priority in the patient’s life. If attending college, the student and family can inquire about care and support groups offered by the college to students with diabetes. College health officials and at least a small group of new acquaintances should be informed about the student’s diabetes, including roommates, dormitory supervisors, and other appropriate college staff members (Roemer, 2016).

(See also “Resources” at the end of this course.)

PARENTS’ ROLE IN PREPARING THEIR CHILD TO MOVE AWAY FROM HOME

Parents often confide to the clinician their fears and anxieties about their child with diabetes moving away from home. On one hand, they want their child to be independent and pursue their own dreams and goals; on the other hand, they may worry about “what if” horror scenarios associated with diabetes. Clinicians can remind parents that their involvement in the move can be a great support. For instance, they can help ensure their child has new healthcare providers in place, prepare sick-day supplies for their child’s new home, and confirm their child has renewable prescription orders and monthly reminders set up at a nearby pharmacy.

The diabetes management team discusses various issues with the young adult and their parents and reviews strategies for possible problem scenarios that may occur when living independently or with a new roommate. Examples include:

How will you manage low blood sugar during the night?
What will you do if you run out of insulin late at night?
Who will be your point of contact for emergencies?
What will you do if checking your blood sugar and administering insulin conflicts with class time or work shifts?
What approaches will you use to deal with stress, such as exams?
What action will you take if you find a cut or sore on your foot that is not healing?
What will you do if you do not like your new healthcare provider?
(Roemer, 2016)

The list of possible situations introduced by diabetes care team members may trigger further questions from the young adult and/or family. The most important issues to address are those posed by the young adult, and the best interventions are those that are practical and workable in each unique patient situation.

An important teaching point the clinician emphasizes to the patient is to take all their insulin doses at the scheduled times. Another important recommendation is for the patient to keep a glucagon emergency kit with them at all times and to teach others how to use it. Following these steps can alleviate many potential problems (CDN, 2019b).

CASE

Kevin is 17 years old and was first diagnosed with type 1 diabetes when he was 6. He’s now a senior in high school and plans to go to college in a few months. During a routine visit, the clinician pays special attention to the pattern of behavior that has typified Kevin’s visits and diabetes management.

Kevin is polite, enjoys talking about school and sports, and keeps his blood glucose readings up to date on his smart phone. He has been independent in administrating insulin since his early teens. However, his parents take responsibility for all other aspects of diabetes management, such as meal preparation, calorie counting, sick-day management, and collecting insulin prescriptions from the pharmacy. When the clinician asks what preparations Kevin and his parents have made for managing his diabetes at college, Kevin looks to his parents, who respond, “We haven’t thought about it yet.”

The clinician is aware that, although Kevin is independent in checking his blood glucose and administrating insulin, he has not yet taken ownership of full management of his diabetes. This is an important step that must be achieved if he is to live safely away from home when he moves away to attend college. The clinician makes several recommendations in this regard:

That Kevin start attending his appointments for diabetes care on his own. His parents may be apprehensive about this, but the clinician can explain this will allow Kevin to develop self-advocacy skills. The clinician can also point out that, as a 17-year-old young man, Kevin may wish to discuss issues with his provider that he will not raise in front of his parents.
That Kevin attend a consultation with the dietitian to review mechanisms for calorie counting and how that best can be accomplished living in a dorm and when selecting a college meal plan.
That Kevin read up about the College Diabetes Network and list at least three recommendations he finds on their website that he will follow up on.

The clinician provides Kevin’s parents with time to talk about their fears and concerns and acknowledges that it is a challenging time for them also. The clinician points out there are several steps they can take to ensure college is a safe and positive transition for Kevin. The clinician helps the parents to put together a plan that includes the following steps:

Check with their healthcare carrier to ensure their present policy will continue to cover Kevin when he moves away from home.
Meet with the social worker on the diabetes management team to identify providers close to Kevin’s intended college who have experience working with college students with diabetes.
Set up a meeting with the college healthcare center for themselves and Kevin in order to learn about available services and programs he could benefit from, such as a diabetes support group for students.
Help Kevin put together an emergency contact list he can call on once he moves to college.
Put together sick-day supplies Kevin can keep in his dorm room.

The clinician also explains to Kevin and his parents that preparation for transitioning to college is not a one-time event; it is a process that takes several months to successfully complete.