reducing-30-day-rehospitalization-of-diabetics In the United States (US) alone, diabetes mellitus (DM) affects approximately 30.3 million Americans, accounting for 9.4% of the country’s population, with a projected increase of up to 438 million by 2030 (Centers for Disease Control and Prevention [CDC], 2019). Those diagnosed with DM are at increased risk of developing severe health problems and comorbidities that could lead to multiple re-hospitalizations. DM is a manageable chronic illness, but it does require vigilant self-care management (Keene, Guo, & Murillo, 2017). Poorly managed DM can cause not only financial and mental strain, but also severe health problems that could lead to multiple re-hospitalizations and complications (Fortmann, Gallo, & Philis-Tsimikas, 2011). Established national guidelines by the Professional Practice Committee of the American Diabetes Association (ADA) (2019) are in place to help those with diabetes, but approximately half of the diagnosed US population has poor diabetic self-care management (DSCM) (Ali et al., 2013). Furthermore, the ADA does not provide actual guidelines in managing how to transition patients from the inpatient setting to the outpatient setting, only that it is significant (ADA, 2019)


Across literature, several different factors have been identified as risks for 30-day readmissions. Hemoglobin A1c (HbA1c) of greater than ten, both hypo- and hyperglycemia, and general prolonged hyperglycemia were all shown to be risks for readmission (Bansal et al., 2017). Poor medication compliance and inadequate post-discharge care and education can significantly impact the risk of readmission (Liu, Liu, Lv, Li, Cui, & Ma, 2014). However, because most studies have been retrospective in nature, results have been both significant and insignificant (Sonmez, Kambo, Taha, & Poretsky, 2016). Therefore, the purpose of this paper is to utilize a review of literature to determine the effect of appropriate and effective discharge education on 30-day hospital readmissions for diabetic patients, while understanding its effect on health promotion and the utilization of Nola Pender’s Health Promotion Model.

I. Introduction

Diabetes Mellitus
For the body to utilize food as energy, the food needs to be converted into a simple sugar known as glucose. Glucose travels throughout the body via the bloodstream. However, glucose cannot enter cells on its own; it must rely on a hormone called insulin to help it into the cell, subsequently lowering the blood glucose level. Diabetes mellitus is a disease involving the pancreas, which is the organ in the body that produces insulin (Cleveland Clinic, 2019). Insulin is critical for maintaining optimal blood glucose levels (Cleveland Clinic, 2019). Without insulin, the body can experience hyperglycemia, or simply, high blood sugar. Therefore, if the pancreas cannot produce insulin, or is unable to keep pace with the daily rise of glucose, this can lead to one of two types of DM.
Type 1 diabetes mellitus. Type 1 diabetes mellitus (T1DM) occurs when the body’s immune system attacks and destroys the β-cells of the pancreas, which specifically produce insulin (ADA, 2019). As a result, glucose builds up in the bloodstream, unable to be utilized as energy for the body. Unfortunately, because the β-cells are damaged, people diagnosed with T1DM must use insulin injections for the rest of their lives to help control their blood glucose levels. T1DM is more common in people under the age of 30 but can occur at any time (Cleveland Clinic, 2019). It affects approximately 10% of those diagnosed with DM (Cleveland Clinic, 2019).
Type 2 diabetes mellitus. Type 2 diabetes mellitus (T2DM) is a condition in which the body becomes insulin resistant (ADA, 2019). Those with T2DM already do not utilize insulin properly. The pancreas attempts to produce more insulin in order to manage the influx of glucose over time, but eventually become unable to produce enough insulin to maintain optimal glucose levels. Instead, the glucose stays in the bloodstream, resulting in the higher than normal levels, leading to hyperglycemia. This can often be managed with diet and an active lifestyle, but some diabetics may need supplemental medication. T2DM generally affects people over the age of 40 and accounts for approximately 90% of the diabetic population (Cleveland Clinic, 2019). DM is generally diagnosed by checking the HbA1c levels in a person’s blood. Hemoglobin A1c. While in the bloodstream, glucose molecules attach to HbA1c, a protein on the surface of a red blood cell (National Institute of Diabetes and Digestive and Kidney Disease [NIDDK], 2019). When blood glucose levels are consistently high, the HbA1c levels are also elevated because there are more glucose molecules attached to the protein and reflects a three-month period. Prediabetes levels currently range from 5.7% to 6.4% and DM is diagnosed at 6.5% or above on two separate tests (NIDDK, 2019).

Risk factors. While exact causes are still unclear, there are several risk factors that can lead to T2DM. Having prediabetes is a risk factor and a precursor diagnosis to T2DM. Additional risk factors include being overweight; being 45 years or older; having a family history; being physically active less than 3 times a week; and being African-American, Hispanic-American, or American Indian (CDC, 2019).
Complications. As the blood continues to retain high levels of glucose, the body begins to suffer immediate and long-term complications. The immediate complications can be elevated glucose levels, known as hyperglycemia, leaving the body’s cells starved for energy. However, the long-term complications of uncontrolled diabetes and hyperglycemia can lead to such diseases as congestive heart failure, limb amputation and gangrene, blindness, peripheral neuropathy, recurrent infections, ulcers, chronic kidney disease, and eventually death (ADA, 2019).
Cost. In 2012, the cost of 30-day hospital readmissions for patients with DM was estimated to be approximately $245 billion (ADA, 2019; Rubin, 2015). Approximately 43% comprised of inpatient care while 18% went into medications solely treating complications of DM (ADA, 2012; Burke & Coleman, 2013). Because of these expenses, there has been a rising effort to understand and reduce re-hospitalizations due to DM and its complications (Ostling et al., 2017). Thirty-day readmission rates for diabetic patients has been estimated to be 14.4-22.7%, with an estimated cost of $25 billion specifically for readmissions (Burke & Coleman, 2013). The financial burden of not just DM but the consequences of poorly-managed DM that lead to readmissions is overwhelming for both healthcare and patients. However, despite these concerns, there has been little understanding for the reasons of increased readmissions and poor DSCM, particularly in the low-income population (Rubin, Donnell-Jackson, Jhingan, Golden, & Paranjape, 2014).
Current care guidelines. The ADA annually releases a set of current care guidelines on how to improve and promote care for patients with T2DM (ADA, 2019). The guidelines focus on having providers give care in a timely fashion while working collaboratively with patients to provide for individual needs and preferences. All follow-ups should include a comprehensive medical exam as recommended by the ADA. The ADA recommends that DSCM should focus on nutrition therapy (weight management, alcohol, and nonnutritive sweeteners); physical activity of 60 minutes a day, unless contraindicated; management of psychosocial issues such as diabetes distress; and the prevention and delay of T2DM, as well as the management of T1DM (ADA, 2019). Medication management guidelines are used in conjunction with weight management, glycemic control, and HbA1c control.

Self-Care Management

Self-care management refers to the ability and knowledge of an individual to navigate the course of diabetes at home (Cooper, Booth, & Gill, 2003; Paterson & Thorne, 2000). According to the American Association of Diabetes Educators (2008), there are seven elements that encompass good self-care management: healthy eating, being physically active, monitoring of blood sugar, compliant with medications, good problem-solving skills, healthy coping skills and risk-reduction behaviors. Background and Significance
Of the 30.3 million Americans with DM, 29.05 million suffer specifically from T2DM (ADA, 2015). In California, an estimated 13 million adults had either diabetes or undiagnosed DM, while another 2.5 million were already diagnosed with DM (ADA, 2015). In all, a total of 15.5 million people, or 55% of the California population, is affected by DM (ADA, 2015). A 2015 survey found an estimated 9.8% of the Los Angeles (LA) County population was found to have DM, with 76% (573,000) of those having T2DM (Desire Health Magazine [DHM], 2016). While California ranked 29th of all the states in terms of incidences of DM, 55% of the California population affected in some way by diabetes, and two in five adults in LA County either have prediabetes or are undiagnosed (DHM, 2016), and with an estimated 1.5 million people newly diagnosed annually in the US, DSCM is more important than ever (ADA, 2015).

Prevalence of DM is important for developing and delivering proper DSCM. Breakdown of race are as follows: non-Hispanic whites (7.4%), Asian Americans (8.0%), Hispanics (12.1%), non-Hispanic blacks (12.7%), and American Indians/Native Americans (15.1%) (ADA, 2015). Twice as many more men are affected by T2DM than women (ADA, 2015). While it is not known what percent of the diabetic population is also in the low-income population, the prevalence of DM is increasing more rapidly in low-income areas than it is in higher-income areas (World Health Organization [WHO], 2015). The percentage of men versus women was nearly half, with 50.8% of the DM population being women (CDC, 2015). Breakdown by age group are as follows: ages 18-44 (13.0%), ages 45-64 (46.5%), and 65 and older (43%) (CDC, 2015). While the highest prevalence of DM is among Hispanics, the greatest increase in prevalence is currently among Asians (ADA, 2015).

Diabetes is the seventh leading cause of death, with 332,341 diabetes-related deaths in 2015 alone (ADA, 2015). Combined with the significant costs that come not only with DM, but also complications related to DM, finding a strategy to improve DSCM and reduce costs, complications, and death is ever more critical. Diabetes is a complicated disease that requires a strict lifestyle of glucose monitoring, medication adherence, diet control, and routine (Swami & Korytkowski, 2017). But research has found that DSCM is further complicated when patients with diabetes are admitted into the hospital and are faced with new medications and restrictions that can uproot their regimen at home (Umpierrez et al., 2012). While these implications have raised questions on how to prevent hospital readmissions, many hospitals and facilities do not have any guidelines or plans of actions for educating patients on transitioning home (Donihi, 2017).

Literature Review

A systematic review of literature between 2015 and 2019 was conducted using EBSCOHost, Medline, and CINHAL. Search terms included diabetes, high blood sugar, hyperglycemia, readmission, and re-hospitalization, resulting in 2,275 articles total. Inclusion criteria included peer-reviewed, scholarly research journals and dissertations, adults (ages 18 and older), English language, and a diagnosis of DM, with a focus on barriers and intervention strategies. Exclusion criteria included the pediatric population, duplicates, international studies involving developing or third-world countries, and non-English language articles. Once applied, a final count of 13 articles was identified. These studies all found that an intervention of timely and appropriate transitional

Access to Education
Health literacy. Three articles noted a lack of health literacy as a barrier to proper DSCM. According to the CDC (2019) health literacy is the extent to which a person is able to obtain, understand, communicate, and utilize health information and services provided to them. Because DM is a disease that requires the patients themselves to fully manage their care, understanding the diagnosis and the necessary care becomes crucial (Swami & Korytkowski, 2017). These findings suggest that patients have a poor understanding of not only what DM entails, but the actual requirements needed to control it when on their own at home (Rubin, 2015). While some patients understood the necessary components of DSCM – such as healthy eating habits, physical activity, and glucose monitoring – many did not know or understand the full details of what these components entailed (Fritz, 2017). These patients were unaware of the type, intensity, or duration of physical activity needed, or that, while fruits are considered healthy, they are dangerous for diabetics (Fritz, 2017). For some, the components of DSCM were clear, but patients chose to follow their own interpretations due to poor health literacy (Fritz, 2017). Such gaps in health literacy can place diabetics at great risk for poor DSCM, glycemic control, increased complications, and even death (Fritz, 2017).

Lack of appropriate education. But low health literacy did not just involve an inability to understand the disease process and how each component worked to create optimal glycemic control. Five of the articles reviewed noted a lack of understanding in how to transition from an inpatient setting – with a primary or secondary diagnosis of diabetes – to an outpatient setting where these individuals are suddenly forced to come to terms with a new set of routines for DSCM (Gregory, Seley, Dargar, Galla, Gerber, & Lee, 2018; Ostling et al., 2017; Rubin, 2015; Sonmez, Kambo, Taha, & Poretsky, 2016; Swami & Korytkowski, 2017). Improvement of DSCM and reduction of compilations and readmissions are highly dependent upon the patient’s ability to understand what brought about these complications – such as elevated HbA1c and multiple hospital readmission – and how to manage them once they leave the hospital (Ostling et al., 2017; Rubin, 2015; Sonmez et al., 2016). By focusing on the correlation of HbA1c and exacerbations of DM and comorbidities, and teaching patients how to manage their care during recovery and after discharge as maintenance, patients are able to reduce the risk of hospital readmissions and even future complications (Gregory et al. 2018; Rubin, 2015; Sonmez et al., 2016).


Multidisciplinary teams. Seven studies found that the use of a multidisciplinary team (MDT) was highly effective in reducing 30-day readmissions in patients with diabetes (Bansal et al., 2018; Chai, Tonks, & Campbell, 2015; Drincic, Pfeffer, Luo, & Goldner, 2017; Marušić et al., 2018; Simmons et al., 2015; Sonmez et al., 2016; Sullivan, Hays, & Alexander, 2019). Patients who were followed during the admission by a diabetes team – which often included an endocrinologist or specialty nurse practitioner (NP), pharmacist, nutritionist, social worker, and case manager – were 50% less likely to be readmitted than those who were not (Bansal et al., 2018; Sonmez et al., 2016). Most hospitals in the United States (US) only provide a primary care team (PCT) to care for these high-risk patients (Bansal et al., 2018). But a MDT specialized in diabetes significantly reduce costs and 30-day readmissions (Bansal et al., 2018; Chai, Tonks, & Campbell, 2015). In fact, Chai, Tonks, & Campbell (2015) found that pre-discharge education was more effective than intensive primary care follow-up. However, this is not to say that aggressive transitional care education followed by post-discharge transition of care should be dismissed (Sonmez et al., 2016). An MDT of transitional care clinics, DM team follow-up, and pharmacist home-visits or telephone visits were found to be just as important in reducing 30-day readmissions (Sonmez et al., 2016).
One of the six articles focused on the importance of pharmaotherapeutic education prior to discharge. In a prospective randomized study, Marušić et al. (2018) found that the intervention group that received 30-minute education sessions with a trained physician or practitioner discussing detailed instructions regarding medication dose, administration, adherence, and consequences of nonadherence. While all participants received pamphlets with the same information, this study found that those patients who received physical and verbal face-to-face education were significantly able to maintain medication adherence post-discharge (22.7% higher), an important value to note because medication adherence has been found to be more important in DSCM than any other factor (Marušić et al., 2018).
Two of the six articles placed the charge of health coaching on case managers (CM). Sullivan, Hays, & Alexander (2019) and Drincic, Pfeffer, Luo, & Goldner (2017) noted the importance of improving DSCM through self-coaching to increase medication compliance, lifestyle changes, and behavior modification. While the case manager did not provide any education regarding diabetes, he or she scheduled follow-up telephone conferences, phone calls, and administered tools such as the Diabetes Education Quiz to create goals and provide accountability for compliance with medications and follow-ups. These patients who received health coaching through case management were far less likely to be readmitted within 30 days than their counterparts.
Specialized diabetes registered nurses/nurse practitioners. Two articles noted the importance of a specialty educator – either a registered nurse (RN) or an NP. Hospitals that chose to educate RNs and NPs to be diabetes champions experienced fewer 30-day readmission rates (Drincic, Pfeffer, Luo, & Goldner, 2017; Gregory et al., 2018). These educators were spent additional time educating patients in honing survival skills that would be crucial post-discharge (Drincic, Pfeffer, Luo, & Goldner, 2017). While having a MDT focused on DM is most effective, Gregory et al. (2018) notes the infeasibility of relying on this team alone to manage all the education necessary. By having a specialized RN or NP educator, the workload is dispersed, and quality pre-discharge education can be provided (Gregory et al., 2018).
Pre-discharge education. Six studies focused on patients receiving inpatient diabetic education and its impact on reducing glycemic control and, subsequently, reducing hospital readmissions and complications. By incorporating inpatient diabetes education during the hospital stay, 30-day readmission risk was reduced by almost 20%, and post-discharge follow-up helped to reduce the 180-day readmission risk from 28% to 3.2% (Rubin, 2015). A study not included in the literature review found that formal diabetes education could reduce all-cause 30-day readmissions by 34% (Healy et al., 2013). Formal education differs from informal education by teaching patients “survival skills”, such as proper recognition of hypo- and hyperglycemic events, medication administration, carbohydrate counting, and glucose monitoring (Chai, Tonks, & Campbell, 2015; Gregory et al., 2018; Swami & Korytkowski, 2017).
The study by Marušić et al., (2018) identified the significance and effectiveness of providing pre-discharge pharmacotherapeutic education to those patients going home after a diabetes-inclusive admission. Ostling et al. (2017) took it one step further by focusing on the type of formal education provided by inpatient management teams to patients discharging from the hospital: the Hyperglycemic Intensive Insulin Program (HIIP), which utilizes a multidisciplinary team that is concurrently led by the endocrinology team, and is also separate from the primary inpatient team; and the Endocrine Consults, which is a team managed by a first-year endocrine fellow and leaves most of the education and outpatient care to the primary team. Unsurprisingly, patients who received education from either HIIP or ENDO had a decreased likelihood of being readmitted. However, those patients who received ENDO were less likely to be readmitted than those who received HIIP (14.8% vs. 17.4%), possibly indicating that a holistic approach that included collaboration between a range of providers was more effective in preventing unscheduled readmissions (Ostling et al., 2017). The significance of these three studies is useful when considering a direct correlation between DSCM and hospital readmissions from an inpatient-to-outpatient point of view. All three studies, however, noted that education during admission and as a post-discharge follow-up was not enough to reduce readmission; risks and reasons for poor DSCM, which is associated with readmissions, needed to be identified and addressed (Gregory et al., 2018; Ostling et al., 2017 Rubin, 2015;).
Telephone follow-up. Three studies found that post-discharge follow-up using mobile devices were critically useful in reducing 30-day readmission and increasing medication adherence. By utilizing a telephone meeting system, providers are ensuring that post-discharge patients are receiving relevant and timely follow-up, rather than leaving patients to attempt to attend in-office visits (Swami & Korytkowaski, 2017). The case managers who provided health coaching noted that those patients who continued to interact via mobile phone during the five scheduled meetings were significantly less likely to be re-admitted (Sullivan, Hays, & Alexander, 2019). In this particular study, case managers provided reminders for medications and doctors’ visits, follow-up calls, and accountability after discharge. When providers utilized a mobile phone (either voice or text message) system of follow-up post discharge, not only did 30-day readmissions reduce, but patients noted a better rate of compliance, ease of transition, motivation to change health behaviors, and trust with providers (Burner, Lam, DeRoss, Kagawa, Menchine, & Arora, 2018; Swami & Korytkowski, 2017). Patients were enrolled in a 6-week time-frame with twice-daily messages that consisted of a mixture of motivational messages medication reminders, trivia questions, and healthy living challenges (Burner et al., 2018).

Pender’s Health Promotion Model and Diabetes Mellitus
Pender’s Health Promotion Model (HPM) uses three core concepts of (1) individual characteristics and experiences, (2) behavior-specific cognitions and affects, and (3) behavioral outcomes. This means that every individual has unique characteristics and experiences that will affect how and why he or she models certain behaviors. Within the HPM, there are four assumptions that must be made and followed for it to be effective: (1) individuals seek to actively regulate their own behavior; (2) individuals are progressively transformed by, as well as transform, the environment around them; (3) health professionals constitute part of that environment; and (4) self-initiated reconfiguration of the person-environment interactive pattern is essential to change (Pender, 2011). The model finds that individual characteristics and experiences will affect behavior-specific cognitions and affect, and eventually affect the behavior outcome, which includes a change in health-promoting behavior.
The idea of improving DSCM for patients who are transitioning home works particularly well with the HPM because effectively management DM requires all four assumptions. DSCM requires work on the part of the individual, with support and outreach from providers. At the same time, the three core concepts of HPM allow for these changes to be tailored to the patient. In order for transitional education to be effective, it must take into consideration the patient’s personal experiences and behaviors in order to have the most impactive change in that patient’s self-care lifestyle. Patients not only need to be educated on the proper habits, medication usages, disease effects, and lifestyle changes necessary to avoid returning to the hospital, but they also need to be educated on how their particular situation is affected by these choices.
Since the HPM focuses on adopting both general and individualized changes that will ideally translate into continuous and consistent healthy behaviors, this can be used to potentially impact high readmission rates as well as provide long-term effective DSCM while patients are at home. This model will help to develop a strategy that not only considers the NP’s requirements for DSCM, but also the patient’s needs in maintaining proper DSCM. Pender’s model brings in multiple viewpoints to create a strategy that utilizes all aspects of DSCM (Pender, 2011).

Clinical Practice Guidelines and Health Promotion

The ADA annually releases an extensive clinical practice guideline (CPG) for the management of diabetes and provides an abbreviated summary of changes on its website. The ADA’s CPG goes well into the different categories of DM, including Type 1, Type 2, gestational and what is labeled as “other” (ADA, 2019). Objectives of the CPG are clearly stated, including health intent, prevention and screening guidelines, expected outcomes, and targeted populations, including the pediatric population, geriatric, and maternity. While stakeholders are not necessary stated, because the target population is undoubted physicians and providers who give care to those patients with or at risk for diabetes, as well as the diabetic population themselves, it can be said that the stakeholders here are those individuals who care for diabetic patients.
The ADA creates its guidelines based on evidence-based practice and studies, although those are not clearly stated within the guidelines. Limitations, pros, and cons are discussed throughout the CPG, as well as the risks and benefits of certain treatments for particular populations. The ADA updates the CPG annually, providing an abbreviated version on the website and as a downloadable PDF file, and provides the entire extended guideline on its website. The changes are clearly listed very early within the guidelines so that they are immediately visible to the reader.

The entire DM CPG is clearly organized by categories, screening and prevention, treatment guidelines, and further education and discussion. The entirety of the guideline is fairly easy to follow, despite how extensive it can be. Unfortunately, because diabetes is such a large facet of health, there is no way to shorten it into algorithms that might be easy to follow. For such an overwhelming project, it is clear, concise, and educational. Additional materials are provided as smaller algorithms, tables, and guidelines that allow for snap-shot visuals, although they are not nearly as comprehensive as the text. No criteria is given for monitoring adherence to guidelines.

In relation to the Project at hand, the ADA guidelines provide a small excerpt that discusses the importance of providing transitional care education and guidelines, but it does not go further into how to go about it. The guidelines provided are useful for outpatient long-term management but considering that 30-day readmissions due to diabetes have been enormously costly and detrimental physically, emotionally, and financially, it is surprising that there is not a more detailed guideline to the education and transition necessary for successful care at home post-discharge. Furthermore, the ADA guidelines do not take into consideration individual affects and needs, as these are general guidelines for a general population. They are useful starting points, but it is ultimately up to the provider to determine the needs of each patient.

This Project attempts to remedy these two points, by providing a transitional education guideline and providing tools and questionnaires that help to individualize the care and education that should be provided for inpatient diabetics as they prepare to discharge home.  


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