A nurse-led transitional care intervention to prevent readmissions in a low-income-serving urban U.S. hospital

Background: Diabetes-related hospital readmissions within 30-days are costly and an indicator of suboptimal care resolution. Nurse-led transitional care interventions may improve glucose control and reduce emergency department recidivism following hospital discharge in very low-income populations. Methods: An intention-to-treat design with randomization of participants (n = 108) compared conventional care to transitional care coordination that included diabetes specialty appointments, monthly support telephone calls, medication management, and tailored diabetes self-management education. Both the control and intervention group received a diabetes specialist and primary care appointment. Results: There was a significant difference between the control and intervention groups (P = 0.018) from baseline to study-end with the intervention group experiencing a 1.9% mean change (SD, P = 0.003) in A1c in those with baseline poor glucose control (A1c>9%) and a trend toward all cause emergency department recidivism (P = 0.06). Both the control and intervention groups benefitted from linkages to specialist care, but the nurse-led group had greater outcome improvements. Conclusion: Hospitalized patients with poor glucose control (A1c>9%) benefit from a nurse-led intervention to provide tailored transitional care and diabetes self-management education. Results of this study showed clinical improvements in glucose control and reduction in 30-day hospital readmissions.