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Bridging the Gap: Post-Discharge Telephone Support for Diabetes Self-Management
Addo, Ivana
Addo, Ivana
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Abstract
Diabetes can complicate medical and surgical conditions leading to increased rate and frequency of hospitalizations. Diabetes can be a source of significant social and economic burden costing over $400 billion in both direct and indirect medical costs. Poor self-management and disease progression are significant factors leading to increasing hospitalizations. The cycle of readmissions can result in fragmented care coordination, inadequate symptom management, and poor outcomes. The purpose of this quality improvement project was to implement a post-discharge phone call intervention determine patients’ confidence level in their ability to self-manage their diabetes and to identify any post-discharge self-management knowledge deficits.
The intervention was implemented through an outpatient endocrinology clinic. Eligible participants were adults aged >18 years with a diabetes mellitus 1 or 2 diagnosis who were recently discharged from an inpatient hospital admission. Telephone calls were conducted within 2-3 days of hospital discharge using a structured telephone script assessing the participants’ diabetic self-management knowledge. Confidence was measured using the Perceived Competence for Diabetes Scale (PCDS). Qualitative inductive coding was the method of analysis used. Three main themes were established: (1) balance of diabetes management and primary admitting diagnosis management (2) hypoglycemia/Hyperglycemia understanding and (3) caregiver involvement and education needs. Participants who were newly prescribed insulin had the lowest average PCDS scores, indicating a greater need in glycemic control education. The implementation of a telephone-based transitional care intervention can provide a connection between in-hospital diabetic education and diabetes self-management when a patient is home by reinforcing the education provided during their inpatient hospitalization, identifying patient concerns and issues early. These phone calls can also provide clarification of discharge instructions or provide additional education regarding various aspects of diabetes management during the vulnerable post-discharge period.
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Date
2026-01-01