Effective diabetes care after hospitalization is commonly limited by poor care coordination. Key information from hospitalization is often not communicated to outpatient clinicians as diabetes is rarely the reason for admission. Published interventions to address this problem are limited or lack sustainable benefit. We studied the effectiveness of Sweet Transitions (ST), a program providing and coordinating diabetes care after hospitalization. Sweet Transitions enrolled patients at a 750-bed hospital with poorly controlled diabetes (A1C ≥ 9%) for visits and phone communication with a nurse practitioner and diabetes educator. The ST dyad provided education, identified barriers, adjusted medication, and coordinated care within the organization and community. An individualized plan was transferred to the clinician responsible for diabetes care. Readmissions for ST patients were compared to matched controls, and A1C was assessed before and after ST intervention. For a median of 43 days, 197 patients participated in the program (64% male, age 52 ± 0.9). In 160 patients with repeat A1C at 131 ± 7 days, A1C decreased from 12.0 ± 0.1 to 9.1 ± 0.2% (p <0.0001), and A1c decreased to ≤ 8.5% in 52%. A1C reduction was sustained in 94 patients with repeat A1C at 378 ± 5 days (12.0 ± 0.1 to 9.0 ± 0.3%, p<0.0001). There was a trend toward lower 30-day readmission rates in ST patients (11% vs. 17%, p=0.08). Readmissions were commonly elective among cardiovascular (CV) admissions (46 vs. 11%). Further analysis by admission diagnosis showed lower readmission rates in ST patients admitted for non-CV reasons vs. matched controls (8 vs. 17% p=0.02). Sweet Transitions was associated with improved glycemic control that persisted at 1 year as well as lower readmission rates. Sustained improvements at 1 year suggest effective engagement and communication at the level of patient, organization, primary care, and community. Scalability of ST’s effectiveness relies on identifying factors and processes contributing to improved outcomes.


K. Berger: None. A. Corbin: None. P. Kamal: None. N.E. Bachman: None. L.A. Riddell: None. M. Falciglia: None.

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