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Learning Objective 1: Describe four pillars of care transition and its use in providing framework for decreasing 30-day readmission for patients with diabetes/hyperglycemia recently discharged from the hospital
Learning Objective 2: Describe Stanford Self-Efficacy for Diabetes scale and its use to measure changes in paitent self-efficacy before and afte their visit to Transition Clinic
Objective 2: Describe Stanford Self-Efficacy for Diabetes scale and its use to measure changes in patient self-efficacy before and after their visit to Transition Clinic.
Purpose:
Test feasibility of a nurse managed clinic for patients recently discharged from hospital with a diagnosis of diabetes. The study will determine if transition clinic (TC) will increase number of patients with scheduled appointment for follow up care within two weeks of discharge, decrease 30-day readmission rate, and increase patient self-efficacy for diabetes self-management.
Methods:
Design: Descriptive, non-randomized.
Sample: 75 inpatients to be enrolled at discharge. Inclusion: Discharge to home from any unit at Queen’s Medical Center with diagnosis of diabetes or hyperglycemia, and followed by Inpatient Diabetes Team (IDT). Exclusion: Severe cognitive deficit, serious mental illness, limited English proficiency.
Recruitment/Retention: Patients who fit criteria identified daily by APRN of IDT. Enroll 75 participants, with expectation 50 will keep their appointment in TC. When 50 participants have kept their appointment, enrollment will stop.
Results:
Enrollment was slower than anticipated. With 49 patients enrolled in study, 27 patients have attended the TC. 30 day readmission for them is 7%. Dropout rate is 59%. One overestimated assumption was difficulty of getting a timely appointment with a PCP. As the health care environment movs toward patient centered health care home, it may be that primary care access for urgent problems is improving. Stanford Self Efficacy for Diabetes scale revealed a significant improvement in patient’s confidence in knowing what to do when blood glucose level are higher or lower than goal.
Conclusion:
The Transition Clinic was feasible, provided benefit to a number of patients, and was a good fit with the services currently provided in the Diabetes Education Center.