Heartbeat: Transitioning team move towards a smoother process

June 28, 2021

Ensuring that our young patients are ready for the transition to adult services is a vital step in their care to ensure it goes as smoothly as possible.

Transition Key Worker, Kelly Edie-Fisher, is tasked to do just this and works with services to improve the process for young people.

Working with NHS England/ Improvement, the team has taken part in a national collaborative to improve the transition in healthcare.

Using a programme called Ready Steady Go, helps the child and their parents to gain the knowledge and skills to manage their condition. It improves long-term outcomes and helps them gain the confidence and skills to move into adult services.

The team focused on 14-year-olds with diabetes with the aim of 79 per cent completing the “Ready” transition stage and have a corresponding plan by the end of March.

Improvements included identifying the dedicated time in the nurses’ very busy diaries to complete the transition appointments, as well as feedback questions being incorporated into an app already used by the paediatric diabetes team.

This will help identify areas for future improvement and development. So far, the young people and parents who have completed feedback have all indicated they found the appointment helpful. A parent commented: “The appointment was great. All relevant areas were covered.”

“It’s been a successful project,” said Kelly. “One of our key learning points was that our initial SMART aim was too large, so we revised it. We then worked on our project charter and the process map, and we continue to complete our Plan, Do, Study, Act (PDSA) cycles as we learn. We will do further work to plan how we can sustain the improvement changes.”

A mid-project session took place with Angela Horsley, Head of Children and Young People at NHS EI and Nathan Samuels, Transition Regional Nurse Advisor, to assess the work done to improve the process.

Speaking of the work at the Trust, Angela said: “I had a positive virtual visit to the Trust and was pleased to be accompanied by Nathan Samuels and Giselle Padmore Payne from the steering group.

I am pleased that the team have taken part in the national collaborative to Improve Healthcare Transition.

It was evident at the visit that the team are passionate to get the transition right for the young people within their population. I feel sure that their improvement project can only benefit these young people, improving their health outcomes.”

Kelly added: “They were very complimentary on what we had achieved. It’s been a real team effort, with great support from others within the Trust.