Health care transitions (HCTs) encompass a structured strategy outlining the transfer of responsibilities, knowledge, and resources from a pediatric to adult health care system. Adolescence refers to the period of transition between childhood and adulthood, with core features such as biological growth and development, uncertainty, and other competing life demands. These developmental changes can hinder effective type 1 diabetes (T1D) management, resulting in suboptimal glycemic control in this transition age group when compared to other age groups.1,2
To support successful transitions from pediatric to adult care, this article provides a roadmap that can be used as a clinical aid to guide clinicians in a systematic HCT process. The roadmap is intended to fill the gaps in care that exist for adolescents during a critical transition period. Key findings from a pediatric endocrinology clinic’s quality improvement initiative that introduced the HCT roadmap will also be discussed.
Recent data from the T1D Exchange Clinic Registry in the United States illustrates a peak of glycosylated hemoglobin (A1C) at 9.3% in midadolescence, with only 17% of patients <18 years of age reaching the American Diabetes Association (ADA) target of <7.5%.3 Deficient patient and caregiver preparation, inadequate documentation, time restraints, ineffective communication, insufficient coordination, personal attachment to pediatric clinicians, and feelings of uncertainty about the expectations in adult care settings have contributed to less favorable HCTs.2,3
Additionally, inadequate clinician training, a lack of consensus on evidence-based guidelines to facilitate optimal care transfers, a paucity of available clinician resources, and low clinician confidence on how to initiate effective transitions have been reported to contribute to poorly executed HCTs in the adolescent population with T1D.3,4 Goethals and colleagues1 assessed the perspectives, resources, and behaviors of 531 diabetes care and education specialists, who reported 4% of the time having youth participate in a transition program. These HCT challenges have been associated with poor self-management, high rates of health-related complications, increases in posttransition hospitalizations and readmissions, and high rates of patient and caregiver dissatisfaction with the overall HCT process.3
Recent data from the T1D Exchange Clinic Registry in the United States illustrates a peak of glycosylated hemoglobin (A1C) at 9.3% in midadolescence, with only 17% of patients <18 years of age reaching the American Diabetes Association (ADA) target of <7.5%.3
A research study that explored transition experiences in 164 individuals ages 18 to 25 diagnosed with TID from 12 hospitals found that almost 35% of the participants self-reported high levels of emotional distress due to adverse HCT experiences. Less favorable HCTs were also associated with lower transition readiness scores and decreased self-management and psychosocial outcomes.2
A systematic review by Schmidt and colleagues5 identified positive health outcomes with a structured HCT process focused on transition planning and care coordination.
Although recommendations have been made by multiple organizations, such as the American Academy of Pediatrics (AAP), ADA, and International Society of Pediatric and Adolescent Diabetes, HCT implementation is lacking.3 A systematic review by Schmidt and colleagues5 identified positive health outcomes with a structured HCT process focused on transition planning and care coordination. Outcomes from the review included a decrease in A1C reported in 53% of the studies and an overall 60% increase in clinic attendance and decrease in hospitalization rates.5 Smooth and seamless handovers that facilitate continuity of care across health care settings can improve health care quality, promote patient follow-up compliance, enhance patient experiences, and promote favorable health-related trajectories.5
Clinician education and training is required to implement a seamless, effective, and sustainable transition program for adolescents with T1D.
The Got Transition’s 6 Core Elements of HCT (6CEoHCT) highlights 6 elements essential to transition care. The 6CEoHCT, a federally funded initiative, was developed in 2011 as a high-priority action by the American College of Physicians, American Academy of Family Physicians, and AAP with the goal of producing a seamless and high transition success rate as evidenced by measurable outcomes, such as decreases in A1C levels, high preventive screening rates, fewer reported hypoglycemic episodes, and increases in transition readiness scores and diabetes-related knowledge scores.4 The elements include the following5:
Policy/guide development
Tracking and monitoring
Patient readiness
Planning stages
Transfer of care
Transition completion.
In addition to these elements, communication and relationships are also fundamental during the HCT process. Clinician communication is important to assess transition readiness, patient and family perceptions of the transition, and their willingness to engage in the process. Talevski and colleagues6 asserted that the teach-back method, an evidence-based communication strategy, can improve knowledge acquisition, self-care capabilities, health literacy, and patient outcomes in individuals with chronic conditions.
The primary aim of this initiative was to introduce a roadmap to help guide clinicians to incorporate a tailored and structured HCT process in a pediatric and adolescent diabetes clinic located within a children’s hospital. The roadmap delineates the expectations for clinicians, caregivers, and patients as they proceed through the transition process. The secondary aim was to deliver well-coordinated care to youth diagnosed with T1D, address fragmentation in health care delivery, heighten acquisition of patient knowledge, improve self-efficacy, support behaviors that promote patient engagement, transfer medical information, expand clinician collaboration, and foster interdisciplinary teambased care.
Clinician education and training is required to implement a seamless, effective, and sustainable transition program for adolescents with T1D. To determine the impact of a clinical seminar that introduced a roadmap to help guide effective HCT, a comparative pretest and posttest design assessing clinician’s knowledge, attitudes, and behaviors regarding the HCT process was used. All clinicians working in the hospital’s pediatric endocrinology clinic were invited to participate in an educational seminar that focused on the 6CEoHCT, clinician role and responsibilities, benefits of HCT, evidence-based implementation strategies, and how to use the HCT roadmap in clinical practice. The roadmap highlights the key steps for effective and safe transitions. The posttest was administered 3 weeks after the seminar to assess for changes in clinician knowledge, attitudes, and behaviors related to the transition process and to help identify gaps in knowledge that can be addressed in future educational programming.
To motivate clinicians and to promote a solid foundation for change, Kurt Lewin’s change management theory was used.7 Lewin’s theory outlines how individuals react, resist, and adapt to changes over time. It consists of 3 steps: (1) unfreezing, (2) moving, and (3) refreezing.7 First, during the unfreezing stage, key stakeholders utilize their curiosity to investigate potentials for what they envisioned could improve the HCT process. During this stage, the project leader communicated the potential benefits of utilizing the 6CEoHCT model and teach-back method of communication as an approach to improve the clinic’s HCT process.
The moving stage focuses on motivating clinicians to move toward the change created during the first stage by providing dedicated guidance, tailored support, and ongoing reinforcement of the benefits the change would bring to the facility. This program focused on experiential learning, with an emphasis on practical applications, and unfreezing the minds of the clinicians. The program materials included background information and evidence supporting the 6CEoHCT and teach-back method of communication in addition to the roadmap clinical tool used to help clinicians incorporate the model into their clinical practice.
The refreezing stage, also referred to as the equilibrium stage, focuses on creating a new balance within the diabetes clinic. This is the stage where the change has been embedded, the clinicians’ qualms or concerns associated with change are lifted, and a new comfort zone is reached. During this stage and throughout the implementation process, adjustments can be made to reinforce HCTs. Overall, the goal is to increase the intrinsic motivation of clinicians to utilize the 6CEoHCT approach to HCT in adolescents diagnosed with T1D as they transition from a pediatric to adult health care system to improve patient and caregiver experiences and health outcomes.
A roadmap was designed as a clinical tool to support clinicians in the endocrinology clinic during patient encounters focused on the 6CEoHCT approach and teach-back method (Figure 1). As a supplement to the educational intervention, the roadmap serves as a visual reminder of the HCT process and aids clinicians in the implementation of change. It identifies the ages and steps of the 6CEoHCT.
As a supplement to the educational intervention, the roadmap serves as a visual reminder of the HCT process and aids clinicians in the implementation of change.
The roadmap’s design shows a street with cars because adolescents are excited and eager to learn how to drive. The goal is to prompt adolescents to be excited and eager to learn and take part in their HCT. The roadmap includes the stages of the 6CEoHCT and the optimal ages at which each step takes place. For example, the pink section of the roadmap focuses on Core Element 1, the transition guide, in which the conceptual model for the transition is created. This conceptual model identifies that the transition ideally begins at age 12 and can be used to educate patients with T1D, caregivers, and staff about the HCT process. Age 12 marks the beginning of early adolescence, and as the child enters Erik Erickson’s “identity versus role confusion” stage of development, it is important that more decision-making opportunities and responsibilities are offered regarding their chronic condition and unique needs so they can begin to develop a stronger sense of self and identity.
The blue section in the roadmap describes the third core element, which emphasizes the transition-readiness assessment. As noted in the green section of Figure 1, the ADCES7 self-care behaviors are highlighted as a reminder of what categories are to be assessed regarding selfmanagement skills.
The current literature reports that a fundamental component to the transition process is the standardized assessment of patient readiness.3 The blue cars depict the 5Ts of teach-back, which include (1) triage, (2) tools, (3) take responsibility, (4) tell me, and (5) try again. The 5Ts of teach-back were developed by Anderson and colleagues8 based on the standardized operational definition of teach-back and its observable components.
In this endocrinology clinic setting, the transition-readiness assessments based on the ADCES7 self-care behaviors are used in the first “T” to triage areas of self-management in which the patient feels confidence or lack thereof. The tools used to educate the patient in the second step are based on clinician preference. The third “T” is significant for the nonshaming aspect of the method because it emphasizes acknowledging the depth and complexity of the information and presents the review of the information as a test of the effectiveness of the clinician’s communication. The fourth “T” is the tell me step in which the clinician asks the patient to state in their own words what was described to them. In the fifth step, try again, if the patient did not understand, the clinician attempts to explain again in another way. The teach-back method is a person-centered approach that focuses on shared understanding of the patients’ knowledge, perceptions, and situations and on the clinicians’ communication.
The yellow section of the roadmap focuses on Core Element 4, transition planning, which incorporates more education and a time in which the adolescent should have some time alone to speak with the clinician. The orange section combines Core Elements 5 and 6, which are the transfer of care and transition completion. Transfer of care occurs when the patient is provided with all their resources to attend their first adult appointment, which includes a medical summary and transition-readiness assessments. Transition completion involves following up with the patient 3 to 6 months after the last pediatric visit to ensure the patient attended their first adult visit and to close the loop of communication. The roadmap provides clinicians with a constant reminder of the HCT process; and keeps patients, families, and clinicians accountable; and is meant to be easily accessible in the clinical setting.
A total of 21 clinicians, including physicians, advanced practice registered nurses, registered nurses, and medical assistants, voluntarily participated in this study. Knowledge, behaviors, and attitudes were assessed before implementation, and 3 weeks later, participants were invited to complete a posttest survey. All categories of assessment presented statistically positive improvements from before the implementation to after the implementation.
In the pretest, more than half (52.4%) of participants reported that the transition process began at ages 18 to 21, with only 19% identifying the start of transition planning at age 12. In the posttest, 81% of participants correctly identified 12 years of age as the start of transition planning. Pretest scores regarding feeling comfortable transitioning adolescents with T1D from the pediatric care setting to the adult care setting showed 42.9% of participants disagreed (n = 6) or strongly disagreed (n = 3). In the posttest, 100% of participants agreed (n = 11) or strongly agreed (n = 10) that they felt comfortable transitioning adolescents with T1D from the pediatric care setting to an adult care setting. Before the intervention, 52% were aware of tools such as the 6CEoHCT framework, while others were either unsure (43%) or said no such tools existed (5%). After the intervention, all participants (100%) indicated that tools to assess transition readiness were available to them through the transition roadmap.
In the posttest, 100% of participants agreed (n = 11) or strongly agreed (n = 10) that they felt comfortable transitioning adolescents with T1D from the pediatric care setting to an adult care setting.
The roadmap was introduced to clinicians in the pediatric diabetes clinic to address the need for clinical tools that highlight the necessary steps to favorable HCTs and to guide clinicians in implementation. The roadmap enabled clinicians to feel more equipped in the HCT process. Communication and education gaps among clinicians involved in the HCT process represent the basis for this initiative. Despite the evidence supporting the use of the 6CEoHCT in transition processes and the teach-back method of communication in patient and clinician communication, there remains a lack of implementation. This roadmap facilitates and summarizes the key aspects of a seamless HCT with application made available in various care settings.
Carolina M. de Almagro, DNP, APRN, FNP-BC, is with Florida International University and Nicklaus Children’s Hospital in Miami, FL. Deana Goldin, PhD, DNP, APRN, FNP-BC, PMHNP-BC, is with Florida International University in Miami, FL. Jacquelyn Verme, MSN, PPCNP-BC, CDCES, and Adriana Carrillo, MD, are with Nicklaus Children’s Hospital in Miami, FL.
Carolina de Almagro, Deana Goldin, Jacquelyn Verme, and Adriana Carrillo developed and wrote the initial draft of the article; all of the authors revised the article for final submission.
The authors declare having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.
The authors declare having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.
Carolina M. de Almagro https://orcid.org/0009-0008-9313-6199
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