1. Development of a Diabetes Transition Program at the Medical University of South Carolina SCTR Scientific Retreat on Transition of Care Across the Lifespan February 8, 2016 Katherine Lewis, MD, MSCR Assistant Professor Division of Endocrinology, Diabetes, and Medical Genetics Division of Pediatric Endocrinology and Diabetes

2. Introduction 2011: Exploration into development of diabetes transition program in pediatric endocrinology – Internal Medicine/Pediatrics trained endocrinologist, dedicated pediatric endocrinology outpatient social worker, ongoing commitment of dietician, CDE, nursing, other physicians – Informal discussions, informal patient survey, review of literature

3. Introduction Response to development of educational programs and support groups limited Wanted to target high risk patients first

4. DKA Study (2012) Objective: To characterize the pediatric patients with known diabetes who are admitted to MUSC in Diabetic Ketoacidosis (DKA) Retrospective chart review of DKA admissions in 2011 Lewis KA, Dixon F, Paulo R, Bowlby D; Poster presentation at Pediatric Academic Societies Meeting, May 2013

5. DKA Study 2012 All Patients Single DKARecurrent DKA N33 2112 Age at time of DKA (years) 14.14 ± 2.68 13.50 ± 2.88*15.27 ± 1.93* Gender Female, (%)17 (52%) 9 (43%) 8 (67%) Ethnicity, (%) White Black Native American 22 (67%) 10 (30%) 1 (3%) 14 (67 %) 6 (29%) 1 (5 %) 8 (67%) 4 (33%) 0 A1C (%)11.7 ± 2.0 11.3 ± 2.411.6 ± 1.90 Outpatient clinic visits in previous year 2.5 ± 1.69 2.42 ± 1.662.27 ± 1.49 Medicaid Insurance Self-Pay 52% 45% 3% 11 (52%) 1 (5%) 9 (43%) 9 (75%) 0 (0%) 3 (25%) Psychological Diagnoses 12 (36%)5 (29%)7 (58%)

6. DKA Study (2012) Increased psychological screenings – Required psych liaison consult during admission with DKA unless already established with mental health provider Intensive diabetes program: increase visits Validation that adolescent population makes up significant proportion of high risk patients Diabetes care coordinator

7. Transition Program Cohort (2013) Objective: To characterize the initial cohort of patients participating the Diabetes Transition Program at MUSC Retrospective chart review of records for patients enrolled in the program May 31, 2012 to June 1, 2013 Khawaja M, Lewis K, Paulo R, and Bowlby D; Abstract presented in Poster Presentation at Annual Diabetes Fall Symposium for Primary Care Providers, September 2013.

8. Transition Program Cohort (2013) All Patients: N = 133 Average A1C9.17 ± 1.92 Patients with A1C <7.5% 25 (18.8%) Patients with DKA8 (6.02%) Patients with 4 or more visits 42 (32.68%) Annual thyroid screening 98 (73.68%) Annual urine albumin screening 87 (65.41%) Depression diagnosis 21 (15.79%) ADHD diagnosis12 (9.02%) Poor glycemic control Infrequent clinic visits Inadequate laboratory screenings Mental health concerns

9. Transition Program Cohort (2013) Focus on technology: phone apps, continuous glucose monitoring, insulin pump therapy Education on tighter glycemic targets Development of a diabetes flowsheet in the electronic medical record and diabetes interval history sheet Outpatient depression screening for high risk patients

10. Emerging Adult Study (2014) Objective: To characterize the initial cohort of emerging adult patients enrolled in the MUSC transition program from May 31, 2013 to June 1, 2014 who were transferred to adult care Retrospective chart review of 53 patients identified as appropriate for transfer to adult care setting Tumblin L, Lewis K, Paulo R, Bowlby D. Annual Diabetes Fall Symposium for Primary Health Care Professionals, September 2014

11. Emerging Adult Study (2014) All Patients TransitionedLost to Follow-up N37 20 (54%)17 (46%) A1C9.2 ± 2.4 8.9 ± 2.510.2 ± 2.3 # of Patients with A1C <7.5%4 (11%) 4 (20%)0 DKA History # of DKA Episodes # of Patients with DKA 6 4 (11%) 2 1 (5%) 4 3 (18%) Patients with 4 or more annual visits6 (16%) 4 (20%)2 (12%) Discussion of Risk and Substances Driving safety Alcohol safety STD/Contraception Tobacco Use Drug Use 36 (97%) 31 (84%) 14 (38%) 26 (70%) 23 (55%) 20 (100%) 18 (90%) 8 (40%) 17 (85%) 14 (70%) 16 (94%) 13 (76%) 6 (35%) 9 (53%)

12. DKA Study: Follow-up (2015) To compare established diabetes patients with DKA in 2014 with those in 2011 Headden K, Lewis K, Paulo R, Bowlby D; Presented as poster at Annual Diabetes Fall Symposium for Primary Health Care Professionals, September 2015

13. DKA Study: Follow-up (2015) All Patients Single DKARecurrent DKA N27 234 Age at time of DKA (years) 14.12 ± 2.88 13.39 ± 3.1415.65 ± 1.40 Gender Female, (%)16 (51%) 14 (58%) 2 (50%) Ethnicity, (%) White Black Native American 10 (37%) 15 (56%) 2 (7%) 9 (39%) 12 (52%) 2 (9 %) 1 (67%) 3 (33%) 0 A1C (%)11.88 ± 1.68 11.88 ± 1.7511.89 ± 1.60 Outpatient clinic visits in previous year 3.46 ± 1.37 3.47 ± 1.543.34 ± 1.01 Medicaid Insurance Self-Pay 67% 33% 0% 16 (70%) 7 (30%) 0 2 (50%) 0 Psychological Diagnoses 6 (22%)4 (17%)2 (50%)

14. Future Directions Collaborative research with psychiatry to study stress reduction intervention in teens with diabetes Continued psychological screenings and referrals Establishment of a patient navigator Collaboration with other subspecialties who with transition programs Increased involvement of primary care providers and adult care providers

15. Questions?