Design and Implementation of an Intervention for Transitions in Diabetes Care

As obesity and diabetes overwhelm the population, their presence affects various disease processes and is felt throughout the health care system. The sickest population of patients, those in the hospital, require in depth knowledge and education transfer, as they transition from the inpatient to outpatient setting and vice versa. Solid organ transplant patients represent the most medically complex inpatient population, and have an exceptionally high risk of diabetes and uncontrolled blood sugars (hyperglycemia) during such transitions. Although adequate treatment of hyperglycemia through the use of medications such as insulin exists, hypoglycemia can be an unintended high risk consequence. A systematic risk assessment has demonstrated the need for a re-design of the processes and systems of care from inpatient to outpatient in this high risk DM population. The goal of this research project is to 1) design, develop and implement an intervention, using patient and user-centered design methods to address the 3 highest risk failures identified in the transition from in-patient to outpatient DM care and 2) implement the intervention and evaluate its effectiveness on glycemic excursions during inpatient to outpatient transitions. This study will help directly improve clinical care, through the input of all stakeholders in transitional care management, for our sickest cohort of DM patients. This research can potentially benefit all patients who have high blood glucose levels and/or diabetes by examining care and assessing quality and safety in transitional care settings.