Transitional Care of Adult Patients with Diabetes Following Hospitalizations

Purpose: The purpose of this evidence-based practice project was to incorporate a diabetes transitional care program using group visits to improve self-care management behaviors and glycemic control in diabetic patients at a southern California hospital. Background: Diabetes is a challenging healthcare problem associated with significant mortality and morbidity issues. In 2012, 29.1 million people, or 9.3% of the U.S. population, were diagnosed with diabetes, and 28.9 million of those patients were 20 years of age and older. Today, diabetes is of epidemic proportion worldwide, and a projection of 5.4% of the adult population will have diabetes by 2025. The growing incidence of diabetes can be attributed to an increase in obesity, lack of exercise, diet high in processed sugars, and overall lack of diabetes self-care. Research consistently supports transitional care as an effective evidence-based solution for enhancing the overall management of patients with diabetes as reflected in improved self-management and glycemic control. At the project facility, there was no formalized transitional care program for diabetes patients. Practice Change Process: Patients 18 years of age and older, who were hospitalized and had an A1C \u3e 7.5% were selected to participate in the transitional diabetes care program. Following discharge from the hospital, the patients were seen within a 14-day period. Selected participants joined in a 90-minute multi-disciplinary group visit to discuss evidence-based care regarding diabetes management. Patients were educated based on the American Association of Diabetes Education (AADE) - 7 Self-Care Behaviors during their stay in the hospital. The Diabetes Knowledge Questionnaire was administered pre and post practice change in order to measure the patient’s knowledge regarding diabetes self-care management. Results: This evidence-based project had 3 participants who attended the group visits and completed the pre and post intervention. The overall knowledge scores improved from a mean of 72% to 87%, a 15% improvement, while the mean A1C levels were reduced from 9.2% to 7.1%, a 1.9% decrease. Conclusions: Transitional care provides a multi-faceted approach to evidence-based diabetic self-care management. Patients were empowered with self-care knowledge and management skills promoting improved diabetes self-care behaviors and glycemic control. Advanced practice registered nurses (APRNs) possess the knowledge and skills to assume leadership roles in the development and implementation of transitional care programs for diabetic patien