Improving Transitions of Care From Hospital to Community Provider for Patients with Type II Diabetes Mellitus

Poorly coordinated care transitions result in nearly half of discharged patients’ experiencing at least 1 medication error and 1 in 5 Medicare beneficiaries readmitted within 30 days. Repercussions of suboptimal transitions of care greatly impact the nation’s economy costing between $12 billion and $44 billion annually. Ineffective handoffs between providers at hospital discharge contribute to suboptimal patient outcomes; therefore, strategies to improve transitions of care are necessary to provide quality care while decreasing health care expenditure. A quality improvement project was conducted on an inpatient surgical unit to decrease hospital readmissions and emergency department visits. Proposed interventions for patients with type II diabetes mellitus discharged home included (1) a follow-up appointment arranged with an outpatient provider prior to discharge and (2) receipt of a follow-up phone call within 48 to 72 hours. A process for providing discharge information to outpatient providers was assessed. A total of 58 patients met inclusion criteria: 91% patients received at least 1 intervention, 48.2% had a follow-up appointment arranged prior to discharge, and 29.3% received a discharge phone call within the proposed timeframe. There was a significant negative correlation with the number of interventions a patient received and decreased hospital readmissions (r = -.131). Health care in the United States has become increasingly fragmented and highly complex. Nurses have a pivotal role for ensuring patients’ experience a seamless transition throughout the continuum of care. In accordance with achieving a safe, timely, effective, efficient, equitable, patient-centered health care system a bundled intervention methodology may in fact serve to improve patient outcomes while decreasing health care expenditure