Endocrine Abstracts

Aim: Transition to adult diabetes services is associated with deterioration in service experience and outcomes. We describe the early outcomes of the innovative Transition (NHSE) pilot TraSS, to improve services for 16-24 year old young adults (YA).

Method: A failsafe-officer, transition outreach specialist nurse, youth worker, dietician, psychologist, and project manager were recruited. Integrated pathways were created (between paediatric, three adult services and primary care) for recurrent ‘Did not attend’ (DNA) or those ‘unable to contact (UtC)’ and ‘high HbA1c’. Referrals were triaged and patients underwent assessment by youth worker and/or transition outreach nurse and support provided as per need and referral reason. Annual psychology screening was instituted.

Results: 161 referrals were received from February 2023 – May 2024. Primary referral reasons were unable to contact/not attending, high Hba1c, self-management educations, youth-worker intervention, insulin omission, recurrent admissions, and mental health issues. 104 YA were seen and follow up and support was organised following categorisation into high, medium, or low risk. 40 YAs were referred as DNA/UtC and (n = 30) 75% were successfully engaged and supported, and (n = 20) 50% were reconnected to their adult teams. 47 YA have attended over 15 peer support and education activities including technology conference, focus group sessions with bowling and ice skating, online travel webinar, online group pump refresher courses and college education sessions. 12 YA were supported during inpatient admissions with education, adopting technology, emotional and practical support, and referrals to mental health. 7/7 that underwent early data revaluation reduced their Hba1c (10 -60 mmol/mol, median reduction of 15 mmol/mol). Health inequalities encountered and required bespoke support included neurodivergence, learning difficulties, homelessness, care leavers, probation, complex multiple co-morbidities, mental health, and not in education, employment, or training (NEET).

Conclusion: Significant progress has been made, in a brief period, in identifying and supporting YA and their services in an innovative, integrated, and efficient manner. Our findings demonstrate the importance of a dedicated community outreach diabetes nurse and youth worker, working alongside both primary care, paediatric and adult teams. Utilising peer support and addressing health inequalities has been integral to the engagement of YA.