Pediatric to Adult Transition Program Launched at UCSF Madison Clinic

As part of the Diabetes Center’s mission to improve the quality of care for patients, the Madison Clinic for Pediatric Diabetes has implemented a program to assist older youth in their transition to adulthood. Funded by the UCSF Diabetes Family Fund, this “Transition Program” is designed to assist families and youth to be better prepared to take on their future needs in managing diabetes within the context of their new life -- whether it be in college, work, or in their own independent family life.

This innovative, groundbreaking clinical program is designed to improve the patient experience and enhance care for teens and young adults who must learn how to manage their own diabetes care as they become adults. It also assists parents in preparing for their child’s future transition into adulthood. This program was developed with feedback from adolescent, young adults, and parents from the Madison Clinic to ensure that all future adult diabetes needs were met.

Marcela Arregui Reyes serves as the clinic’s first full-time transition coordinator and acts as a liaison between patients and providers throughout the transition process. Marcela meets with patients and their families starting at the age of 14, and conducts annual assessments to better understand each individual’s needs. At times of transition -- high school to college, transition from school to work, planning for future insurance and finding an adult provider in the future – Marcela communicates with all parties involved to ensure a smooth transfer of care.

The transition program incorporates regular group meetings with staff psychologists, as well as evening seminars for patients and their families that address specific topics of concern. A newly created Youth Advisory Board provides a unique outlet for patients to gather informally and share experiences and knowledge.

According to Diana Naranjo, PhD, one of the clinic’s two staff clinical psychologists, countless patients around the country are lost during the shift from pediatric to adult models of care, and this can have devastating consequences on their long-term health. “Historically, this transition period has been looked at with a ‘tag, you’re it’ kind of approach,” stated Dr. Naranjo. “Under this new program, we will work closely with patients many years before they actually make the transition so that when the time comes, they feel empowered and fully capable to be autonomous with their disease management.”

To provide greater continuity of care, the clinic also recruited two endocrinologists who are dually trained in pediatric and adult medicine. They can care for patients from childhood through young adulthood until age 26 with a seamless transition. “Even for children who are cared for by pediatric endocrinologists such as myself, all I have to do when they turn 18 is simply introduce them to their new doctor, but still within the Madison Clinic,” stated Saleh Adi, MD, Medical Director of the Madison Clinic. “They remain in the same place they’re so familiar and comfortable with, with the same staff, nurses and educators. Parents love it; it’s one less thing to worry about.”

The UCSF Madison Clinic at Mission Bay was built to provide the best comprehensive care for children and young adults with diabetes and their families, with an emphasis on patient education, empowerment and the use of advanced technologies. It also has a commitment to advancing research in the management of diabetes in children.