Western Health Region
The Western Health region has a pediatric diabetes patient population of
50-70 patients. The diabetes outpatient clinic, located at the region’s
main hospital, consists of two dieticians, two diabetes nurse educators,
two pediatricians, and adult internists. Patients are assigned to one of
the two pediatricians at diagnosis. There is also a diabetes nurse
educator located in another part of the region who sees patients in
person and uses telemedicine to consult with a pediatrician when needed.
Clinic appointments follow a set structure in terms of seeing the
various members of the health care team and scheduled in advance at
regular intervals.
Transition preparation starts between ages 15-16 when providers begin to
discuss what to expect during transition and patients are encouraged to
attend part of their appointments without their parent or guardian.
Topics are covered through discussion with the staff and educational
resources, such as handouts. If patients stay in the region after their
18th birthday, their physician changes from a
pediatrician to adult internist and the patient must take over the
responsibility of scheduling their own appointments. The rest of the
clinic team, e.g., dieticians, nurses, remain the same. If patients move
out of the region, the team recommends that the patient contact a family
physician in their new location and to get a referral to the local adult
diabetes clinic. The diabetes clinic offers to keep in touch with their
former patients through email to assist with their diabetes management,
as many young adults only move out of the region temporarily for work or
education (Table 2, Quote 4). The clinic staff also allows former
patients to book an appointment without a referral, which allows for
quick reconnection if a patient needs assistance. Because of the ability
for people to reconnect quickly to the diabetes program and the staff’s
familiarity with the patients, the clinic team felt that they are able
to effectively support transition for their population.