Background:
Diabetes is a growing problem in the United States. Increasing hospital admissions
for diabetes patients demonstrate the need for evidence-based care of diabetes patients by inpatient
providers, as well as the importance of continuity of care when transitioning patients from inpatient
to outpatient providers.
Methods:
A focused literature review of discharge planning and transitions of care in diabetes, conducted
in PubMed is presented. Studies were selected for inclusion based on content focusing on transitions
of care in diabetes, risk factors for readmission, the impact of inpatient diabetes education on patient
outcomes, and optimal medication management of diabetes during care transitions. American Diabetes
Association (ADA) guidelines for care of patients during the discharge process are presented, as
well as considerations for designing treatment regimens for a hospitalized patient transitioning to various
care settings.
Results:
Multiple factors may make transitions of care difficult, including poor communication, poor
patient education, inappropriate follow-up, and clinically complex patients. ADA recommendations
provide guidance, but an individualized approach for medication management is needed. Use of scoring
systems may help identify patients at higher risk for readmission. Good communication with patients
and outpatient providers is needed to prevent patient harm. A team-based approach is needed, utilizing
the skills of inpatient and outpatient providers, diabetes educators, nurses, and pharmacists.
Conclusion:
Structured discharge planning per guideline recommendations can help improve transitions
in care for patients with diabetes. A team based, patient-centered approach can help improve patient
outcomes by reducing medication errors, delay of care, and hospital readmissions.
Enhancing Clinical Pharmacy Specialist Involvement in Transitions of Care Focusing on Ambulatory Care Sensitive Conditions within a Veterans Affairs Healthcare System
