Consensus statement on transition for Diabetes
As kaitiaki (caregivers/guardians) of diabetes related services, it is a collective responsibility to establish an environment that facilitates a pathway for people with diabetes to navigate te ao mate huka - the world of diabetes1
Ehara taaku toa i te toa takitahi, engari he toa takitini
My strength is not as an individual but as a collective.
Transition is “a planned, purposeful movement of the adolescent or young adult with a chronic disease from a child (and family) centred to an adult centred health care system.” (ISPAD, 2018)
The transition from a paediatric to an adult orientated service should be an organised process of preparation and adaption, where care is delivered from a healthy youth development approach. The appropriate age for transfer from paediatric to adult care may vary due to the maturity of the young person/rangatahi, the availability of the appropriate service for the rangatahi and local service structures.
Whānau and the wider support network are considered the principal source of strength, support, security and identity hence their involvement is an important consideration in the planning and interaction with rangatahi.
The transition process should occur with adequate timing and appropriate supports. Parents and whānau are vital to the process.
Begin at least 12 months before transferring
Parents/whānau role is emphasised through the whole process and their concerns discussed
Rangatahi and whānau need to be aware of differences between paediatric and young adult/adult services and what to expect
Rangatahi are given the opportunity for privacy and confidentiality unless there are safety concerns
Identification of knowledge issues and diabetes distress so can be addressed as appropriate
Identification of key stakeholders in the life of the rangatahi
The goal of transition to encourage rangatahi to remain engaged in diabetes care and with diabetes care providers. This is achieved through clear communication between paediatric and young adult services, rangatahi and whānau.
Written information made available about new service and team
Written documentation summarising biomedical and psychosocial assessment and cultural engagement.
Psychosocial Assessment including HEEADSSS - mnemonic for Home, Education and Employment, (eating and exercise), Activities and peers, Drugs, Sexuality, Suicide and depression, Safety, Spirituality
Cultural Engagement including marae, connections to iwi, hapu and whānau
Confirmation of receipt of information
Caregivers/whānau are involved and aware
Primary care are included in all correspondence
Youth health information is provided by both services
Welcome to Young Adult Service Pack
Successful transition is determined by rangatahi being engaged with a service by attending appointments regularly or alternatively transferred to a health service that engages with them.
Systematic review of accessibility to service as measured by “Did not attend rates”
Clinicians are actively involved and interested in youth
Rangatahi with diabetes continue to be seen by a specialist diabetes team every 3 months or more if required as recommended by ISPAD (2022).
Member of the multidisciplinary team is designated the Transition Co-ordinator to support the transition process.
1Te Kaiwhakahaere Māori te Roopu mate huka Debbie Rawiri - Te Whatu Ora Waitaha Canterbury
For further information on PSNZ / MoH Clinical Network development, please contact Clinical Networks Support Manager, Karyn Sanson, email@example.com.