Implementation of a Transition Readiness Assessment and Transition Discussion Documentation in a Type 1 Diabetes Clinic

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Authors: Sonalee Ravi, MD; Jaimie Contreras, BSN, RN, CDECS; Julie Kincheloe, BSN, RN, CDECS; Heather Feingold, LSCSW, LCSW; Lydia Sailor BSN, RN, CDECS; Callie Chagas, MS, RD, CDECS; Rebekah Elliott BS, Katelyn Evans, LCSW, LMSW; Diana Ferro, PhD; Emily DeWit, MSAL; Ryan McDonough, DO; Mark Clements, MD PhD

Children’s Mercy Kansas City
Kansas City, Missouri, USA


Our institution utilizes a general transition readiness assessment to facilitate transition discussions. Patients rate six areas of knowledge, eight skills, and confidence in ability to transfer care successfully prior to age 22, then select a goal for their next visit. Discussions are documented in the medical record. Our aim was to implement this assessment with a 20% documentation rate after six months.

In March 2021, we trained providers and diabetes educators about the need for transition planning, the differences between transition planning and transfer, and the need for documentation. We added three diabetes-specific questions related to insulin adjustments, sexual function/pregnancy, and diabetes emergencies to the assessment tool. In April 2021, the transition assessment was implemented in clinic visits and all patients aged 17-years and older were asked to complete the assessment prior to their clinic visit. In June 2021, emails were jointly sent to providers and educators the Friday prior to visit indicating patients who needed transition assessments.

Monthly data were pulled from the medical record that indicated percentage of eligible patients who had a documented discussion.

Our clinic improved transition assessment documentation from 4.81% to 43.75% after six months.

Our clinic successfully increased awareness and use of a general transition readiness assessment to guide transition planning. Future directions include utilizing clinic nurses to provide in-clinic reminders. We will also expand the assessment to younger ages to identify knowledge gaps and provide targeted education videos to improve self-management of diabetes and complete transfer of care.

Key Words:
adolescents, self-management, transition, Type 1 diabetes, young adults

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