TRANSITIONAL CARE FOR ADULT PATIENTS WITH DIABETES MELLITUS
Background: Diabetes is a challenging healthcare problem associated with significant mortality and morbidity issues. In 2012, 29.1 million people, or 9.3% of the U.S. population, had a diagnosis of diabetes mellitus and 28.9 million of those patients were 20 years of age and older. Today, diabetes is of epidemic proportion worldwide and an additional 5.4% of the adult population is projected to be diagnosed with diabetes by 2025. The growing incidence of diabetes can be attributed to an increase in obesity, lack of exercise, diet high in processed sugars, and/or overall lack of diabetes self-management knowledge. Research consistently supports transitional care as an effective evidence-based solution for enhancing the overall management of patients with diabetes as reflected in improved self-management and glycemic control. At the project facility, there is no formalized transitional care program for diabetes patients in place.
Practice Change Process: The purpose of this evidence-based practice project is to enhance diabetes patient self-care knowledge by 20% and improve patient glycemic control by a 10% reduction in HgbA1C levels. Patients 18 years of age and older with a primary or secondary diagnosis of diabetes who are hospitalized and have a HgbA1C > 7.5% will be selected to participate in the transitional diabetes care program. Following discharge from the hospital, the patient will be seen within a14-day time frame. Using Pender’s theory of Health Promotion as a foundation for the project, selected patients will participate in a 90-minute multi-disciplinary medical appointment to discuss evidence-based care regarding diabetes management. Patients are educated on the American Association of Diabetes Education (AADE) - 7 Self-Care Behaviors when in the hospital. The Diabetes Knowledge Questionnaire will be administered pre and post intervention in order to measure the patient’s knowledge regarding diabetes self-care management. In addition, glycemic control will be determined through Hgb A1C levels obtained at baseline and two - three months post-intervention.
Outcomes: In progress. It is anticipated that participants will have a 20% improvement in diabetes self-care knowledge and a 10% reduction in Hgb A1C levels two – three months post intervention.
Conclusions: Transitional diabetes patient care provides a multi-faceted approach to evidence-based diabetes self-care management. Patients are empowered with self-care management skills promoting improved diabetes self-care behaviors and glycemic control. Transitional care can play an important role in improving quality of life, reducing costs, and improving access to health care for adults with diabetes. Advanced practice nurses possess the knowledge and skills to assume a leadership role in the development and implementation of transitional care programs for diabetes patients.