Practical Recommendations for Transitioning Patients with Type 2 Diabetes from Hospital to Home

Abstract

Purpose of Review

The purpose of this review is to provide practical evidence-based recommendations for transitioning hospitalized patients with type 2 diabetes (T2DM) to home.

Recent Findings

Hospitalized patients who have newly diagnosed or poorly controlled T2DM require initiation or intensification of their outpatient diabetes regimen. Potential barriers to medication access and continuity of care should be identified early in the hospitalization. Throughout hospitalization, patients should receive diabetes education focused on basic survival skills and tailored to learning needs. Patients should leave the hospital with personalized discharge instructions that include a list of all medications and follow-up appointments with both the outpatient diabetes provider and a diabetes educator whenever possible.

Summary

An approach to transitioning patients with T2DM from hospital to home that focuses on optimizing the patient’s discharge diabetes regimen, anticipating patients’ needs during the immediate post-discharge period, providing survival skills education, and ensuring continuation of diabetes care and education following hospital discharge has the potential to improve glycemic control and reduce emergency department visits and hospital readmissions.

This is a preview of subscription content, access via your institution.

Fig. 1

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Centers for Disease Control and Prevention. National Diabetes Statistics Report: estimates of diabetes and its burden in the United States, 2014. Atlanta: U.S. Department of Health and Human Services; 2014.

    Google Scholar 

  2. 2.

    American Diabetes Association. Diabetes care in the hospital. Sec. 14. In Standards of medical care in diabetes—2017. Diabetes Care. 2017;40(Suppl 1):S120–S7.

    Article  Google Scholar 

  3. 3.

    Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16–38. doi:10.1210/jc.2011-2098.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2009;15(4):353–69. doi:10.4158/ep09102.ra.

    Article  Google Scholar 

  5. 5.

    Handelsman Y, Bloomgarden ZT, Grunberger G, Umpierrez G, Zimmerman RS, Bailey TS, et al. American Association of Clinical Endocrinologists and American College of Endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2015;21(Suppl 1):1–87. doi:10.4158/ep15672.gl.

    Article  Google Scholar 

  6. 6.

    Hirschman KB, Bixby MB. Transitions in care from the hospital to home for patients with diabetes. Diabetes spectrum: a publication of the American Diabetes Association. 2014;27(3):192–5. doi:10.2337/diaspect.27.3.192.

    Article  Google Scholar 

  7. 7.

    Draznin B, Gilden J, Golden SH, Inzucchi SE, Baldwin D, Bode BW, et al. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care. 2013;36(7):1807–14. doi:10.2337/dc12-2508.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Rodriguez A, Magee M, Ramos P, Seley JJ, Nolan A, Kulasa K, et al. Best practices for interdisciplinary care management by hospital glycemic teams: results of a Society of Hospital Medicine Survey among 19 U.S. hospitals. Diabetes spectrum: a publication of the American Diabetes Association. 2014;27(3):197–206. doi:10.2337/diaspect.27.3.197.

    Article  Google Scholar 

  9. 9.

    American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033–46.

    Article  PubMed Central  Google Scholar 

  10. 10.

    • Rubin DJ. Hospital readmission of patients with diabetes. Curr Diab Rep. 2015;15(4):17. doi:10.1007/s11892-015-0584-7. This overview describes risk factors for and potential ways to reduce hospital readmissions in patients with diabetes.

    Article  PubMed  Google Scholar 

  11. 11.

    Dungan KM. The effect of diabetes on hospital readmissions. J Diabetes Sci Technol. 2012;6(5):1045–52.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Lipska KJ, Wang Y, Kosiborod M, Masoudi FA, Havranek EP, Krumholz HM, Inzucchi SE. Discontinuation of antihyperglycemic therapy and clinical outcomes after acute myocardial infarction in older patients with diabetes. Circ Cardiovasc Qual Outcomes. 2010;3(3):236–42.

    Article  PubMed  Google Scholar 

  13. 13.

    Lovig KO, Horwitz L, Lipska K, Kosiborod M, Krumholz HM, Inzucchi SE. Discontinuation of antihyperglycemic therapy after AMI: medical necessity or medical error? Joint Commission journal on quality and patient safety/Joint Commission Resources. 2012;38(9):403–7.

    Article  PubMed Central  Google Scholar 

  14. 14.

    Wu EQ, Zhou S, Yu A, Lu M, Sharma H, Gill J, et al. Outcomes associated with insulin therapy disruption after hospital discharge among patients with type 2 diabetes mellitus who had used insulin before and during hospitalization. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2012;18(5):651–9. doi:10.4158/ep11314.or.

    Article  Google Scholar 

  15. 15.

    Wu EQ, Zhou S, Yu A, Lu M, Sharma H, Gill J, et al. Outcomes associated with post-discharge insulin continuity in US patients with type 2 diabetes mellitus initiating insulin in the hospital. Hospital practice (1995). 2012;40(4):40–8. doi:10.3810/hp.2012.10.1002.

    Article  Google Scholar 

  16. 16.

    Wei NJ, Wexler DJ, Nathan DM, Grant RW. Intensification of diabetes medication and risk for 30-day readmission. Diabetic medicine : a journal of the British Diabetic Association. 2013;30(2):e56–62. doi:10.1111/dme.12061.

    CAS  Article  Google Scholar 

  17. 17.

    Griffith ML, Boord JB, Eden SK, Matheny ME. Clinical inertia of discharge planning among patients with poorly controlled diabetes mellitus. J Clin Endocrinol Metab. 2012;97(6):2019–26. doi:10.1210/jc.2011-3216.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Montejano L, Vo L, McMorrow D. Transitions of care for people with type 2 diabetes: utilization of antihyperglycemic agents pre- and post-hospitalization. Diabetes Therapy. 2016;7(1):91–103. doi:10.1007/s13300-015-0148-5.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Bergenstal R, Fahrbach J, Iorga S, Fan Y, Foster S. Preadmission glycemic control and changes to diabetes mellitus treatment regimen after hospitalization. Endocr Pract. 2012;18(3):371–5. doi:10.4158/EP11166.OR.

    Article  PubMed  Google Scholar 

  20. 20.

    Lee PH, Franks AS, Barlow PB, Farland MZ. Hospital readmission and emergency department use based on prescribing patterns in patients with severely uncontrolled type 2 diabetes mellitus. Diabetes Technol Ther. 2014;16(3):150–5. doi:10.1089/dia.2013.0168.

    Article  PubMed  Google Scholar 

  21. 21.

    •• Umpierrez GE, Reyes D, Smiley D, Hermayer K, Khan A, Olson DE, et al. Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care. 2014;37(11):2934–9. doi:10.2337/dc14-0479. Prospective study evaluating a strategy for designing a discharge diabetes regimen for patients with T2DM based on admission A1c.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    • Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the study of diabetes. Diabetes Care. 2014;38(1):140. Published guidelines for pharmacological management of patients with T2DM.

    Article  Google Scholar 

  23. 23.

    • Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgarden ZT, Bush MA, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm—2016 executive summary. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2016;22(1):84–113. doi:10.4158/ep151126.cs. Published guidelines for pharmacological management of patients with T2DM.

    Article  Google Scholar 

  24. 24.

    Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, et al. Severe hypoglycemia and risks of vascular events and death. N Engl J Med. 2010;363(15):1410–8. doi:10.1056/NEJMoa1003795.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA. Increased mortality of patients with diabetes reporting severe hypoglycemia. Diabetes Care. 2012;35(9):1897–901. doi:10.2337/dc11-2054.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Goto A, Arah OA, Goto M, Terauchi Y, Noda M. Severe hypoglycaemia and cardiovascular disease: systematic review and meta-analysis with bias analysis. BMJ. 2013;347:f4533. doi:10.1136/bmj.f4533.

    Article  PubMed  Google Scholar 

  27. 27.

    Hsu PF, Sung SH, Cheng HM, Yeh JS, Liu WL, Chan WL, et al. Association of clinical symptomatic hypoglycemia with cardiovascular events and total mortality in type 2 diabetes: a nationwide population-based study. Diabetes Care. 2013;36(4):894–900. doi:10.2337/dc12-0916.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Green AJ, Fox KM, Grandy S. Self-reported hypoglycemia and impact on quality of life and depression among adults with type 2 diabetes mellitus. Diabetes Res Clin Pract. 2012;96(3):313–8. doi:10.1016/j.diabres.2012.01.002.

    Article  PubMed  Google Scholar 

  29. 29.

    Sinclair A, Dunning T, Rodriguez-Mañas L. Diabetes in older people: new insights and remaining challenges. The Lancet Diabetes & Endocrinology. 2015;3(4):275–85. doi:10.1016/S2213-8587(14)70176-7.

    Article  Google Scholar 

  30. 30.

    Kimmel B, Sullivan MM, Rushakoff RJ. Survey on transition from inpatient to outpatient for patients on insulin: what really goes on at home? Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2010;16(5):785–91. doi:10.4158/ep10013.or.

    Article  Google Scholar 

  31. 31.

    • Wei NJ, Nathan DM, Wexler DJ. Glycemic control after hospital discharge in insulin-treated type 2 diabetes: a randomized pilot study of daily remote glucose monitoring. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2015;21(2):115–21. doi:10.4158/ep14134.or. Pilot trial in insulin-treated patients with type 2 diabetes that found high rate of hypoglycemia in the post-discharge transition period in patients randomized to daily remote glucose monitoring.

    Article  Google Scholar 

  32. 32.

    Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755–65. doi:10.7326/0003-4819-147-11-200712040-00006.

    Article  PubMed  Google Scholar 

  33. 33.

    Umpierrez GE, Dungan K. Update on inpatient diabetes management: call for action. Diabetes Technol Ther. 2015;17(4):225–8. doi:10.1089/dia.2014.0283.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Peterson G. Transitioning from inpatient to outpatient therapy in patients with in-hospital hyperglycemia. Hospital Practice. 2011;39(4):87–95. doi:10.3810/hp.2011.10.927.

    Article  PubMed  Google Scholar 

  35. 35.

    Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG. American Diabetes Association Diabetes in Hospitals Writing Committee: management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27. doi:10.2337/diacare.27.2.553.

  36. 36.

    Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169–74. doi:10.2337/dc12-1988.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med. 2011;154(8):554–9. doi:10.7326/0003-4819-154-8-201104190-00007.

    Article  PubMed  Google Scholar 

  38. 38.

    Raz I, Mosenzon O. Early insulinization to prevent diabetes progression. Diabetes Care. 2013;36:S190–S7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    O’Malley CW, Emanuele M, Halasyamani L, Amin AN. Bridge over troubled waters: safe and effective transitions of the inpatient with hyperglycemia. J Hosp Med. 2008;3(5 Suppl):55–65. doi:10.1002/jhm.355.

    Article  PubMed  Google Scholar 

  40. 40.

    Cook CB, Seifert KM, Hull BP, Hovan MJ, Charles JC, Miller-Cage V, et al. Inpatient to outpatient transfer of diabetes care: planning for an effective hospital discharge. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2009;15(3):263–9. doi:10.4158/EP.15.3.263.

    Article  Google Scholar 

  41. 41.

    Hodge C, Malaskovitz J. Addressing glycemic targets from diagnosis to discharge. Diabetes spectrum: a publication of the American Diabetes Association. 2014;27(3):169–73. doi:10.2337/diaspect.27.3.169.

    Article  Google Scholar 

  42. 42.

    Wheeler K, Crawford R, McAdams D, Robinson R, Dunbar VG, Cook CB. Inpatient to outpatient transfer of diabetes care: perceptions of barriers to postdischarge followup in urban African American patients. Ethn Dis. 2007;17(2):238–43.

    PubMed  Google Scholar 

  43. 43.

    • Rubin DJ, Donnell-Jackson K, Jhingan R, Golden SH, Paranjape A. Early readmission among patients with diabetes: a qualitative assessment of contributing factors. J Diabetes Complicat. 2014;28(6):869–73. doi:10.1016/j.jdiacomp.2014.06.013. Analysis of interviews of patients with diabetes who were readmitted within 30 days of a previous hospitalization to determine factors contributing to the readmission.

    Article  PubMed  Google Scholar 

  44. 44.

    Leichter SB, August GL, Moore W. The business of hospital care of diabetic patients: 2. A new model for inpatient support services. Clinical Diabetes. 2003;21(3):136.

    Article  Google Scholar 

  45. 45.

    Armor BL, Wight AJ, Carter SM. Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up. J Pharm Pract. 2016;29(2):132–7. doi:10.1177/0897190014549836.

    Article  PubMed  Google Scholar 

  46. 46.

    Shah M, Norwood CA, Farias S, Ibrahim S, Chong PH, Fogelfeld L. Diabetes transitional care from inpatient to outpatient setting: pharmacist discharge counseling. J Pharm Pract. 2013;26(2):120–4. doi:10.1177/0897190012451907.

    Article  PubMed  Google Scholar 

  47. 47.

    Lauster CD, Gibson JM, DiNella JV, DiNardo M, Korytkowski MT, Donihi AC. Implementation of standardized instructions for insulin at hospital discharge. J Hosp Med. 2009;4(8):E41–2. doi:10.1002/jhm.489.

    Article  PubMed  Google Scholar 

  48. 48.

    Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926–43. doi:10.1016/j.pec.2015.11.003.

    Article  PubMed  Google Scholar 

  49. 49.

    Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Hess Fischl A, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care. 2015;38(7):1372.

    Article  PubMed  Google Scholar 

  50. 50.

    • LaManna JB, Bushy A, Norris AE, Chase SK. Early and intermediate hospital-to-home transition outcomes of older adults diagnosed with diabetes. The Diabetes educator. 2016;42(1):72–86. doi:10.1177/0145721715620020. Study identifying factors affecting transition outcomes of older adults with diabetes.

    Article  PubMed  Google Scholar 

  51. 51.

    Nettles AT. Patient education in the hospital. Diabetes Spectrum. 2005;18(1):44.

    Article  Google Scholar 

  52. 52.

    • Korytkowski MT, Koerbel GL, Kotagal L, Donihi A, DiNardo MM. Pilot trial of diabetes self-management education in the hospital setting. Prim Care Diabetes. 2014;8(3):187–94. doi:10.1016/j.pcd.2013.11.008. Randomized study evaluating impact of an individualized structured diabetes education plan created by a CDE and delivered by nursing staff.

    Article  PubMed  Google Scholar 

  53. 53.

    Donihi AC, Yang E, Mark S, Sirio C, Weber R. Scheduling of pharmacist-provided medication education for hospitalized patients. Hosp Pharm. 2008;43(2):121–6.

    Article  Google Scholar 

  54. 54.

    Wexler DJ, Beauharnais CC, Regan S, Nathan DM, Cagliero E, Larkin ME. Impact of inpatient diabetes management, education, and improved discharge transition on glycemic control 12 months after discharge. Diabetes Res Clin Pract. 2012;98(2):249–56. doi:10.1016/j.diabres.2012.09.016.

    Article  PubMed  PubMed Central  Google Scholar 

  55. 55.

    Leichter SB. The business of hospital care of diabetic patients: 1. Is it time to reconsider the model for educational services? Clinical Diabetes. 2003;21(2):78.

    Article  Google Scholar 

  56. 56.

    Dulipsingh L, Gaudian B, Spurrier W, Taylor L, Wakefield D, Rychlewicz S, et al. Educational intervention along with standardization of diabetes care increased inpatient HbA(1c) testing: a pilot program. Conn Med. 2016;80(4):231–7.

    PubMed  Google Scholar 

  57. 57.

    •• Hardee SG, Osborne KC, Njuguna N, Allis D, Brewington D, Patil SP, et al. Interdisciplinary diabetes care: a new model for inpatient diabetes education. Diabetes spectrum : a publication of the American Diabetes Association. 2015;28(4):276–82. doi:10.2337/diaspect.28.4.276. Description of a patient-centered interdisciplinary diabetes care model implemented at tertiary care teaching hospital after loss of a team of dedicated diabetes educators.

    Article  Google Scholar 

  58. 58.

    Munoz M, Pronovost P, Dintzis J, Kemmerer T, Wang NY, Chang YT, et al. Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice. Joint Commission Journal on Quality and Patient Safety. 2012;38(5):195–206.

    Article  PubMed  PubMed Central  Google Scholar 

  59. 59.

    • Dungan K, Lyons S, Manu K, Kulkarni M, Ebrahim K, Grantier C, et al. An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2014;20(12):1265–73. doi:10.4158/ep14061.or. Trial found significant reductions of A1c in patients with baseline A1c >9% who receive a combination of comprehensive inpatient education and post-discharge support.

    Google Scholar 

  60. 60.

    • American Association of Diabetes Educators. Role of the diabetes educator in Inpatient diabetes management. 2016. https://www.diabeteseducator.org/practice/practice-documents/practice-statements. Position statement of the AADE on the role of the diabetes educator in inpatient diabetes management.

  61. 61.

    • Krall JS, Donihi AC, Hatam M, Koshinsky J, Siminerio L. The nurse education and transition (NEAT) model: educating the hospitalized patient with diabetes. Clinical Diabetes and Endocrinology. 2016;2(1):1. doi:10.1186/s40842-016-0020-1. Study describes challenges to providing inpatient diabetes education, and identifies strategies for providing bedside nurses with teaching tools and resources.

    Article  Google Scholar 

  62. 62.

    Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care. 2013;36(10):2960–7. doi:10.2337/dc13-0108.

    Article  PubMed  PubMed Central  Google Scholar 

  63. 63.

    Koproski J, Pretto Z, Poretsky L. Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care. 1997;20(10):1553.

    CAS  Article  PubMed  Google Scholar 

  64. 64.

    Jornsay DL, Garnett ED. Diabetes champions: culture change through education. Diabetes Spectrum. 2014;27(3):188.

    Article  PubMed  PubMed Central  Google Scholar 

  65. 65.

    Corl DE, Guntrum PL, Graf L, Suhr LD, Thompson RE, Wisse BE. Inpatient diabetes education performed by staff nurses decreases readmission rates. AADE in Practice. 2015;3(2):18–23.

    Article  Google Scholar 

  66. 66.

    Abduelkarem AR. Assessment of diabetes-related knowledge among nursing staff in a hospital setting. Journal of diabetes nursing. 2013;17(6):207–10-18.

    Google Scholar 

  67. 67.

    Rubin DJ, Moshang J, Jabbour SA. Diabetes knowledge: are resident physicians and nurses adequately prepared to manage diabetes? Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2007;13(1):17–21. doi:10.4158/ep.13.1.17.

    Article  Google Scholar 

  68. 68.

    Ulrich PA, Abner N. Diabetes under control: meter, meds, meals, move, and more. Am J Nurs. 2010;110(7):62–5. doi:10.1097/01.naj.0000383938.76085.00.

    Article  PubMed  Google Scholar 

  69. 69.

    Uplinger N, Turkel MC, Adams PC, Nelson-Slemmer D, Pierce S. Development of a DiaBEATes nurse champion program. The Diabetes educator. 2009;35(5):713–26. doi:10.1177/0145721709340804.

    Article  PubMed  Google Scholar 

  70. 70.

    Modic MB, Albert NM, Nutter B, Coughlin R, Murray T, Spence J, et al. Diabetes teaching is not for the faint of heart: are cardiac nurses up to the challenge? The Journal of cardiovascular nursing. 2009;24(6):439–46. doi:10.1097/JCN.0b013e3181b1d126.

    Article  PubMed  Google Scholar 

  71. 71.

    Corl DE, McCliment S, Thompson RE, Suhr LD, Wisse BE. Efficacy of diabetes nurse expert team program to improve nursing confidence and expertise in caring for hospitalized patients with diabetes mellitus. Journal for nurses in professional development. 2014;30(3):134–42. doi:10.1097/nnd.0000000000000068.

    Article  PubMed  Google Scholar 

  72. 72.

    Modic MB, Canfield C, Kaser N, Sauvey R, Kukla A. A diabetes management mentor program: outcomes of a clinical nurse specialist initiative to empower staff nurses. Clinical nurse specialist CNS. 2012;26(5):263–71. doi:10.1097/NUR.0b013e318263d73d.

    Article  PubMed  Google Scholar 

  73. 73.

    •• Magee MF, Khan NH, Desale S, Nassar CM. Diabetes to go: knowledge- and competency-based hospital survival skills diabetes education program improves postdischarge medication adherence. The Diabetes educator. 2014;40(3):344–50. doi:10.1177/0145721714523684. Pilot study which found increased knowledge and medication adherence after nurse delivery of standardized DVD-based diabetes education in the hospital.

    Article  PubMed  Google Scholar 

  74. 74.

    Wei NJ, Grant RW, Nathan DM, Wexler DJ. Effect of hospital admission on glycemic control 1 year after discharge. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2012;18(4):456–63. doi:10.4158/ep11309.or.

    Article  Google Scholar 

  75. 75.

    Lavernia F. Treating hyperglycemia and diabetes with insulin therapy: transition from inpatient to outpatient care. Medscape journal of medicine. 2008;10(9):216.

    PubMed  PubMed Central  Google Scholar 

  76. 76.

    • Seggelke SA, Hawkins RM, Gibbs J, Rasouli N, Wang C, Draznin B. Transitional care clinic for uninsured and Medicaid-covered patients with diabetes mellitus discharged from the hospital: a pilot quality improvement study. Hospital Practice. 2014;42(1):46–51. doi:10.3810/hp.2014.02.1091. Randomized controlled study which found patients seen in a transitional care clinic within 5 days of hospital discharge had fewer readmissions.

    Article  PubMed  Google Scholar 

  77. 77.

    Burke RE, Guo R, Prochazka AV, Misky GJ. Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res. 2014;14(1):423. doi:10.1186/1472-6963-14-423.

    Article  PubMed  PubMed Central  Google Scholar 

  78. 78.

    Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission: current strategies and future directions. Annu Rev Med. 2014;65:471–85. doi:10.1146/annurev-med-022613-090415.

    CAS  Article  PubMed  Google Scholar 

  79. 79.

    Wong FKY, Mok MPH, Chan T, Tsang MW. Nurse follow-up of patients with diabetes: randomized controlled trial. J Adv Nurs. 2005;50(4):391–402. doi:10.1111/j.1365-2648.2005.03404.x.

    Article  PubMed  Google Scholar 

  80. 80.

    •• Brumm S, Theisen K, Falciglia M. Diabetes transition care from an inpatient to outpatient setting in a veteran population: quality improvement pilot study. The Diabetes educator. 2016;42(3):346–53. doi:10.1177/0145721716642020. A retrospective before and after study evaluating impact of a multimodal diabetes transitional care program that included diabetes education in the hospital followed by weekly follow-up until first visit with PCP.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The author gratefully acknowledges the helpful critical comments and expert suggestions of Mary Korytkowski, Jodie Reider, Jane Jeffrie Seley, and Linda Siminerio during the preparation of this manuscript.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Amy C. Donihi.

Ethics declarations

Conflict of Interest

Amy C. Donihi declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This review article contains references to studies with human subjects, including some performed by Amy C. Donihi. Please refer to original articles for information regarding informed consent of study subjects.

Additional information

This article is part of the Topical Collection on Hospital Management of Diabetes

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Donihi, A.C. Practical Recommendations for Transitioning Patients with Type 2 Diabetes from Hospital to Home. Curr Diab Rep 17, 52 (2017). https://doi.org/10.1007/s11892-017-0876-1

Download citation

Keywords

  • Type 2 diabetes mellitus
  • Hospital discharge
  • Hospital readmission
  • Inpatient diabetes
  • Transitional care
  • Transitions of care