Diabetes is a complex disease with a range of nuanced therapy options and a plethora of risk factors that could significantly affect patient quality of life and long-term outcomes. From the outset, after diagnosis, a selected regimen has to be meticulously tailored to a patient’s clinical needs and monitored over time, and many other nonclinical variables, such as patient preference, social history, access to care, and support systems, as well as the cost of the drugs and its impact on the patient, must also be considered.
The increase in the incidence of youth-onset diabetes means that more young adults are making the transition from pediatric to adult care, and careful care coordination is paramount at the handover point to ensure that a full and complete account of the history gets transferred to the adult-care provider.
So how do you distill the information from all those records (on paper and online) that you’ve accumulated during the time you’ve been treating a young adult who is now transitioning to adult care?
One resource that can facilitate this handover is the transition summary. It effectively consolidates and packages the aforementioned aspects of care and patient history so that the adult-care provider does not have to collect the patient’s history from the start. The transition summary should not be confused with the discharge or medical summary, which focuses only on the preceding clinical care.
It is important to stress at this stage that collaboration between the pediatric- and adult-care providers is crucial to the success of such a summary, from its creation, to its implementation, and through the subsequent and inevitable revisions and updates.
Benefits all around
After we introduced the transition summary at my institution, we found that the average initial patient visit with the new adult-care provider decreased by 12 minutes (with a range of 6-19 min). The adult-care providers welcomed receiving such detailed, important patient information packaged in a concise and readily accessible format. It helped them identify the preceding care team members, which facilitated continuity of care, and it also helped them forge a better therapeutic relationship with the patient earlier on in their engagement.
We also learned that patients were more comfortable with the transition, and the referring providers were relieved and reassured that their patients would continue to receive personalized care with the new adult-care provider.
At a personal level, I found I was less stressed as I could spend better-quality clinical time with patients. And I got to eliminate those unwieldy stacks of medical records since getting buy-in from divisional and IT leadership enabled us to automate the entire process of information transfer.
It is important to note that the patient has to consent to release of medical records to other institutions.
Setting up the summary
At our clinic, I started out by adapting the transition summary from guidelines provided by the Endocrine Society to make a template. Then, in collaboration with my pediatric colleagues, I removed and added information so that the revised document would contain information that is vitally important and not readily available in the chart and would be feasible to fill out. For example, we included details such as the patient’s psychosocial history, an estimation of the patient barriers to diabetes management, family relationship issues, and the patient’s reasons for not adopting advanced diabetes technology (see accompanying example of a transition summary) .
I kept the summary brief, at two pages, and piloted it with referring providers who were interested in using the summary and with related supporting services. I also sought buy-in from my institution. This meant that I needed pediatric and adult divisional leadership support, which offered me information technology, resources, and expertise to automate the summary within the electronic health record. Once I had feedback from would-be users, we revised and updated the summary. We set up training for staff, including pediatric providers, nurse practitioners, social workers, and nurses who could fill out the summary, and ultimately succeeded in making it mandatory that the adult-care provider receive a summary before scheduling or seeing the transfer patient.
I started out with a paper version, and once we’d refined the questions, we incorporated it into the electronic medical record.
The information we use in our summary is grouped under the following headings: