Diabetes Educators as Transitional Coaches After Hospital Discharge: Impact on Readmission and Glucose Control

Saturday, 28 October 2017

Barbara J. Romig, DNP
College of Nursing, Thomas Jefferson University, Philadelphia, PA, USA

Introduction / Background

A chronic and complex disease identified as the seventh leading cause of death in the United States (U.S.) (American Diabetes Association, 2016), diabetes mellitus contributes significantly to the morbidity and mortality of U.S. citizens. A key driver in improving health outcomes in patients with diabetes is improved self-management of the disease. This Quality Improvement Project presented an innovative approach to improving the care of diabetic patients using hospital-based diabetes educators who became transitional coaches for discharged patients. During phone calls three days, seven days, and thirty days after discharge, nurses working as diabetes educators reinforced patient education and home blood glucose goals, reviewed blood glucose readings and medications, reminded patients about follow up appointments, and answered questions about self-management of diabetes at home.

This project built on an interprofessional care transition model that had been implemented previously and integrated a number of nursing-led, evidence-based strategies to provide intensive intervention to high-risk diabetic inpatients. Collectively, the components of this project provided an innovative approach to ensure the delivery of high quality, continuous diabetes care to high-risk patients from inpatient admission to discharge, and care transitions to home and community.

Clinical Question

The clinical question for this project was: Do high risk hospitalized patients with diabetes who receive patient education by diabetes educators, followed by transitional coaching calls at three days, seven days, and thirty days after discharge have lower A1C levels three months after teaching and lower 30-day and three month diabetes-related readmission rates?


This project involved an interprofessional diabetes education program implemented at Reading Hospital, a 709-bed acute care hospital in southeastern Pennsylvania. A Magnet™ designated, level II trauma center, Reading Hospital has more than 31,000 discharges per year and sees more than 130,000 patients for emergency visits annually.

Population and Sample

The population is comprised of patients with Type I and Type II diabetes who are considered high risk due to poor glycemic control (A1C levels > 7.5%), a new diagnosis of diabetes or altered medical regimen during the hospitalization, patients readmitted for diabetes-related conditions, patients admitted with hypoglycemia or complications of diabetes, or patients who are new to insulin. Inclusion criteria included all high risk diabetic patients as defined above. Patients were excluded who demonstrate healthy self-management practices for diabetes and have A1C levels demonstrating optimal glycemic control (A1C < 7.5%). For patients with dementia or developmental delays, a caregiver was offered the diabetes education and transitional coaching intervention.

Methods / Implementation

Five diabetes educators were promoted in December, 2015 to support the implementation of the Bedside to Home Care Transitions (BHCT) Program, a Health Resources and Services Administration (HRSA) Nursing Education, Practice, Quality and Retention (NEPQR) grant. These nurses working as diabetes educators completed computer-based modules provided by the American Association of Diabetes Educators (AADE) and were mentored by an experienced certified diabetes educator. The five grant-funded diabetes educators were assigned a specific nursing division for which they were responsible to provide diabetes education and transitional coaching. Consults for diabetes education were entered by endocrinologists, hospitalists, and registered nurses. Patients needing diabetes education were also identified by daily lists produced by the Epic electronic health record (EHR). The diabetes educators provided inpatient teaching to patients with diabetes, and conducted transitional coaching telephone calls three days, seven days, and thirty days after discharge. Clinical questions and concerns arising during the transitional coaching calls were referred to the primary care provider.

The patient education intervention provided during the hospitalization was based on the American Association of Diabetes Educators scope and standards of practice (AADE, 2011). Individual teaching sessions were provided one to three times during the hospitalization, depending on the individual patient’s need. Family members or caregivers were invited to participate in the education sessions if they were able. Clinical nurses on the patient care unit reinforced the teaching provided by the diabetes educator, and encouraged patients to self-administer scheduled insulin when they demonstrated readiness to do so.

The AADE7™ Self-Care Behaviors provided the foundation for the education provided to patients with T2DM. These behaviors include: healthy eating, being active, monitoring, taking medications, problem solving, healthy coping, and reducing risks (AADE, 2011). In addition, patients were asked to “teach back” to demonstrate understanding of insulin administration and blood glucose monitoring. During the follow up phone calls three days, seven days, and thirty days after discharge, patients were asked questions about accessing and taking medications; blood glucose monitoring; appointment follow up; and management of hypoglycemia. The survey tool used for follow up calls was developed internally based on the literature about diabetes-related readmissions as well as the expertise of an experienced diabetes educator. The rationale for the content on the follow up survey questions was that gaps in transitions of care and reasons for diabetes-related readmissions typically evolve around these topics. This project provides a foundation for delivering comprehensive and continuous healthcare services to high-risk diabetic patients and their families to meet a demonstrated need for improving diabetes health outcomes.


Improvements in glycemic control as evidenced by reductions in HA1C levels and reductions in readmission rates resulted from the implementation of this quality improvement project (outcome graphs to be included in poster).