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Educational Toolkit for Patients with Diabetes During Transition of Care Calls
Didrikson, Kirsten
Didrikson, Kirsten
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Abstract
Diabetes, in all forms, has an extensive effect on the health of our population. Education in diabetes management is linked to improved outcomes at all stages of one’s diagnosis. Having a multidisciplinary team use educational materials at all points of contact increases patients’ understanding and self-management. The aim of this project was to increase education and self-management of glycemic control for a cohort of patients with T1DM and T2DM through transition of care support with individualized educational material and guidance. Patients were identified through discharge notes to the Nurse Practitioner (NP). The transition of care (TOC) calls were conducted by the Certified Diabetes Educator (CDE) following an established algorithm and evidence-based questionnaire to assess patients’ needs. The CDE then provided evidence-based individualized educational material to support them. A validated tool to assess self-care activities for diabetic patients was administered during the initial TOC call and repeated in 1-4 weeks at their follow-up clinic visit. Six patients were targeted for TOC phone calls, four of the six were successfully reached and completed pre-intervention surveys. Two of the six patients attended clinic follow-up visits and submitted post-intervention surveys. Information about blood glucose monitoring was the most frequently distributed education material. Based on survey results, the number of days patients took their medication increased from 5 to 7, and glucose testing scores remained stable. The project showed modest gains in patient education, with TOC calls improving insulin use and glucose monitoring among those reached. This quality improvement project aligns with existing research demonstrating improved diabetes self-management when discharge coordination and follow-up care are offered via TOC planning.
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2026-05-03
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Educational Toolkit for Patients with Diabetes During Transition of Care Calls
Adobe PDF, 450.95 KB
- Embargoed until 2027-05-04