The Feasibility of a Nurse Managed Transition Clinic for

Monday, 22 July 2013

Grace C. G. Schonhardt, APRN, FNP-BC, CDE
Diabetes Education Center, The Queen's Medical Center, Honolulu, HI
Anne Leake, PhD, APRN, FNP-BC
Inpatient Diabetes Team, Queens' Medical Center, Honolulu, HI
Kelli Williams, APRN, FNP-BC, CDE
Inpatient Diabetes Team, Queen's Medical Center, Honolulu, HI
Chen-Yen Wang, PhD, ANP-BC, CDE
Nursing, University of Hawaii at Manoa, School of Nursing and Dental Hygiene, Honolulu, HI

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 hospital.

Learning 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.


Test feasibility of a nurse managed clinic for patients recently discharged from the hospital with a diagnosis of diabetes.  Using the four pillars of care as a framework, study will determine if transition clinic (TC) will increase number of patients with scheduled appointment for follow up care within two weeks of being discharged, decrease 30-day readmission rate for patients with diabetes, and increase patient self-efficacy for diabetes self-management.


Design:  Descriptive, non-randomized.

Sample:  75 inpatients to be enrolled at discharge.   Inclusion criteria:  Discharge to home from any unit at Queen’s Medical Center with a diagnosis of diabetes or hyperglycemia, and followed by Inpatient Diabetes Team (IDT).  Exclusion criteria: Severe cognitive deficit, serious mental illness, limited English proficiency, and significant pain requiring high doses narcotics.

Recruitment/Retention: Patients who fit criteria identified daily by APRN of IDT.  APRN to enroll 75 participants, with expectation that 50 will keep their appointment in TC.  When 50 participants have kept their appointment, enrollment will stop. 


Enrollment was slower than anticipated.  With 49 patients enrolled in study to date, 27 patients have attended the TC.  30 day readmission for them is 7%. Dropout rate of 59% was higher than the predicted rate of 33%.   One overestimated assumption was difficulty of getting a timely appointment with a PCP.  With the health care environment moving toward a patient centered health care home, it may be that primary care access for urgent problems is improving.  Using the Stanford Self Efficacy for Diabetes scale, there was a significant improvement in increasing patient’s confidence in knowing what to do when blood glucose level goes higher or lower than it should be.


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.