Westmead Hospital’s Diabetes Transition Team celebrates 21 years of innovation

Westmead Health Precinct’s Diabetes Transition Team is jubilantly celebrating 21 years of ground-breaking innovation in healthcare.

The team’s primary focus has been to establish a strong relationship that ensures ongoing follow-up for patients as they grow up, leading to influential changes in self-care behaviour.

Transitioning from paediatric to adult healthcare poses numerous challenges for young people, families, and clinicians, and even in 2023, it remains fragmented for many individuals.

Since 2001, Westmead Hospital’s Diabetes Transition Support Program, spearheaded by Associate Professor Jane Holmes Walker, has been providing invaluable assistance to young adults aged 15-25 with diabetes during their transfer from paediatric to adult healthcare.

This unique model of care promotes efficacy in diabetes self-care, encourages engagement with the care team, and offers continuous support throughout the transition process.

While global health systems recognise the need to establish dedicated clinics for youth with diabetes, only a few centres in Australia and worldwide offer the comprehensive range of services provided by a dedicated diabetes educator/transition coordinator-led model of care.

The program encompasses seven key elements, including care coordination by a Credentialed Diabetes Educator, direct mobile phone access to the service, active appointment management, youth-centred care, an afternoon ‘one-stop-shop’ clinic with extended hours, age-appropriate education, and mobile phone support outside regular hours to provide immediate care advice and prevent emergency department visits.

Initially, the vision was to reduce hospital admissions for young people with diabetes, which were 10 times higher than those seen in adults with type one diabetes aged over 30.

This goal was achieved within the first year of the intervention and has been consistently maintained throughout the program’s lifespan. Prolonged hospital admissions are now rare among individuals under the care of the Westmead Hospital model.

The program’s innovation was evident in 2004 with the introduction of mobile phone technology, enabling text message reminders for upcoming clinic appointments.

This technology, embraced by young adults, extended the care model through a help-line service, allowing them to seek support during acute diabetes crises.

This approach, combined with health coaching, played a crucial role in preventing out-of-hours admissions.

Despite the challenges posed by COVID-19 restrictions, the team leveraged diabetes technology and innovation to provide clinical care through Telehealth, ensuring continued clinic attendance for the population of 250 young people with type one diabetes.

Over the past 21 years, the team has actively researched diabetes outcomes after transition, resulting in notable achievements such as a nursing PhD, 15 direct publications, and five indirect publications from a national benchmarking collaboration with the Australasian Diabetes Data Network.

Advanced trainees, medical students, and nursing staff have all contributed to these research outcomes.

As Westmead Hospital’s Diabetes Transition Team commemorates 21 years of unwavering dedication, their impact continues to empower young adults, transforming lives and shaping a future of self-efficacy in diabetes self-management.