All together: Integrated care for youth with type 1 diabetes

Abstract

Objective: We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional wellbeing, and depression. Research Design and Methods: The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods.Results: There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment.Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team. Conclusion:The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

ISPAD Clinical Practice Consensus Guidelines 2022: Psychological care of children, adolescents and young adults with diabetes

“…Screening and referral alone are not sufficient to impact clinical and psychological outcomes, nor can they ensure referrals are done so that mental health care is actually received 2 . Integrated care models are critical 3–5 …”

“…Standardized and validated questionnaires for psychosocial monitoring, screening, and diagnosis can be used in a stepped approach with positive findings leading to further evaluation 4,5 . Starting with informal verbal inquiries for monitoring well‐being and/or QoL, including mood and distress where positive responses can be probed with additional questions and/or use of standardized measures and finally by structured interviews for diagnosis.…”

“…128 Standardized and validated questionnaires for psychosocial monitoring, screening, and diagnosis can be used in a stepped approach with positive findings leading to further evaluation. 4,5 Starting with informal verbal inquiries for monitoring well-being and/or QoL, including mood and distress where positive responses can be probed with additional questions and/or use of standardized measures and finally by structured interviews for diagnosis. These formal diagnostic assessments and interviews should be conducted by a qualified mental health professional, familiar with the care of young people with diabetes and help guide the selection of most appropriate intervention.…”

“…Given the burden of living with a chronic illness and the greater incidence of mental health problems in youth with diabetes compared to their peers, psychosocial care should be an integral part of the collaborative, person‐centered medical care for youth with diabetes. The Collaborative Care Model (CCM) has emerged as a promising clinical model to facilitate the integration of mental health care with physical health care to simultaneously address co‐occurring physical and mental health problems 5,170 . The shared goal of care should be to optimize health outcomes and QOL.…”

“…Although routine psychosocial screening in pediatric diabetes clinics effectively identifies youth struggling with psychosocial problems and facilitates referrals to appropriate care resources, screening and referral alone are not sufficient to ensure care is actually received 2 . Integrated care models ensure that youth with diabetes access mental health care 3–5 . When screening programs are initiated, there also must be a process for appropriate referrals to address identified concerns.…”