Implementation and Evaluation of an Interdisciplinary and Coordinated Process Focusing on the Transitional Care of High-Risk Adult Patients With Type 2 Diabetes Mellitus and/or Hyperglycemia

Diabetes mellitus is a major and escalating chronic illness that affects more than nine percent of the United States’ population and is the seventh leading cause of U. S. deaths. Many hospitalized patients present without a prior diagnosis of hyperglycemia, but are recognized as pre-diabetic, while others experience transient stress hyperglycemia during hospitalization. Still others present with evidence of poor diabetes self-management, education, and support, and hospitalization provides an opportunity to assess and improve their current health status and glycemic control regimens. A growing body of evidence demonstrates that comprehensive glycemic control and interventions to increase patients’ knowledge and self-care management skills are essential components of treatment, as is continuing support. Passage of the Patient Protection and Affordable Care Act of 2010 has re-focused attention on quality, to include effective patient care transitions, improved self-care management, and avoidable hospital readmissions. The purpose of this study was to describe and evaluate the implementation of an interdisciplinary inpatient diabetes care process that optimizes coordinated care transitions and patients’ self-care knowledge. Although there were no significant differences in 30-day readmission rates or attendance at initial follow-up discharge appointments between the intervention and control groups of this pilot randomized control trial, observational and descriptive aspects of the study provided insight into the study institution’s current processes with regard to standards of diabetes care, patient care coordination, and patient transitions. Deficiencies in these processes led to several recommendations and to the conclusion that implementation of an interdisciplinary diabetes care coordination pathway could be instrumental in improving the delivery and quality of care for patients with Type 2 Diabetes Mellitus.