How can pharmacists help patients with diabetes bridge the inpatient-to-outpatient transition of care gap?

In the very large tertiary care academic medical center where I work as a clinical pharmacist, nearly 30% of all patients have diabetes. Most already carry the diagnosis in their past medical history at the time of admission, but many are new to the diagnosis (although admitted for other reasons). Despite this high prevalence of diabetes, my hospital does not have a dedicated certified diabetes educator (CDE). Shocked? You shouldn’t be. The days of a dedicated hospital-based diabetes educator whose sole job is to provide comprehensive diabetes self-management education (DSME) are long gone in many institutions because hospital administrators believe it is inefficient to pay a CDE to run around the hospital to teach patients with diabetes.

There are many challenges associated with hospital discharge planning for patients with diabetes. These challenges include pressures to discharge the patient early, treatment inertia, and knowledge deficits among practitioners and nursing staff regarding management of diabetes and insulin therapy.¹ Patients are very sick with whatever disease process brought them into the hospital. There is high acuity, and short lengths of stay. But, there are also very good reasons that patients, even those who might have been educated prior to admission, need diabetes education. For example, insulin is the mainstay for glucose management in the hospital setting. This means that nearly all patients new to the diagnosis are given insulin, patients taking non-insulin therapy prior to admission have that therapy switched to insulin, and patients on insulin prior to admission have their insulin therapy changed to the insulin products “on formulary”. Patients, both those new to the diagnosis and those who have carried the diagnosis for years, are often confused about their diabetes management during and following hospitalization.

Diabetes self-management education provides the foundation for self-care and has been shown to improve health outcomes and glycemic control.² Admittedly, DSME should occur in the outpatient setting when the patient is feeling better and is ready to fully participate in the education effort; however, hospitalized patients need to be taught how to safely manage their diabetes until they have the opportunity for comprehensive education as an outpatient.^3,4 In a prospective non-randomized pilot study, hospitalized patients receiving targeted survival skill education from trained research assistants had improvement in diabetes knowledge and medication adherence.⁵ In a retrospective analysis of hospitalized patients with poor glycemic control (A1C >9%), patients who received formal education from a trained diabetes nurse educator had lower all-cause readmission rates.⁶

Despite these data, the burden of diabetes education is often placed on staff nurses in the hospital setting. Theoretically, bedside nurses are in an excellent position to provide patient education since they are in and out of the patient’s room multiple times each day to administer medication and perform their other nursing duties. Since they are near the patient at all times, they can find teachable moments when the patient is awake and able to mentally and physically participate in educational efforts. Unfortunately, bedside nurses have limiting opportunities for training in diabetes-specific topics and they lack confidence in providing accurate information on current therapies.⁷ In addition, there are often high turn-over rates and/or reliance on resource (or registry) nurses who may not be familiar with the expectation of providing diabetes education.

I am often asked by my nurse colleagues to assist with insulin education for patients who are new to insulin therapy. Despite all my efforts to try to get notified of these patients prior to the day of discharge, the “asks” typically come on the day of discharge because there is a delay in identification of the education need. I get excuses like “well, we just realized the patient needs to go home on insulin”, even though the patient had been here for 4 days, had an A1C of 12% on the day of admission, and has had continued hyperglycemia despite daily upward titration of insulin doses since the day of admission. Unfortunately, there are so many competing demands for the patient’s time during hospitalization, and especially on the day of discharge. When I try to see patients, they are often away at a procedure or otherwise unavailable to me when I get to the room. They are bombarded with people needing to see them – consult teams, physical therapists, social workers, respiratory therapists, etc.

I suppose that I empathize with hospital administrators who don’t want to pay a CDE to run around and only see a mere fraction of diabetes patients, but patients need to understand medication changes that are made during hospitalization and what they should do following hospitalization. Patients need to know how going home will affect their glucoses, especially if they are discharged with a steroid taper or have TPN discontinued on the day of hospital discharge. If patients are new to insulin, then they need to know how to administer it, how to monitor their glucoses, and how to identify and treat hypoglycemia. In the real-world setting, how can we ensure that patients receive the appropriate survival skills education prior to discharge – and not wait until the day of discharge to actually give it to them? Providing educational resources and tools to bedside nurses is certainly one answer;⁷ however, it is likely not enough.

Patients with diabetes have a 30-day readmission rate of 14-23%.⁸ A comprehensive plan to prevent hospital readmissions for patients with diabetes is definitely needed. We know that hospitalized patients who received a single 30- to 45-minute counseling session with a pharmacist prior to discharge had greater adherence rates with their diabetes medications and follow-up appointments, and a reduction in A1C compared to a control group receiving nurse-directed standard-of-care education.⁹ Besides education, other interventions that may reduce the risk of early readmission for patients with diabetes include improving communication of discharge instructions, involving patients more in medication reconciliation, and addressing barriers to follow-up care.¹⁰ Pharmacists are well-suited to take a major role in delivering these types of interventions. So, why aren’t there more pharmacists providing this type of care?

1. Cook CB, Seifert KM, Hull BP, et al. Inpatient to outpatient transfer of diabetes care: planning for an effective hospital discharge. Endocr Pract. 2009;15(3):263–9.
2. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-43.
3. American Association of Diabetes Educators. Diabetes inpatient management. Diabetes Educ. 2012;38(1):142–6.
4. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353-69.
5. Magee MF, Khan NH, Desale S, Nassar CM. Diabetes to Go: Knowledge- and Competency-Based Hospital Survival Skills Diabetes Education Program Improves Postdischarge Medication Adherence. Diabetes Educ. 2014;40(3):344-50.
6. Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care. 2013;36(10):2960-7.
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10. Rubin DJ, Donnell-Jackson K, Jhingan R, Golden SH, Paranjape A. Early readmission among patients with diabetes: a qualitative assessment of contributing factors. J Diabetes Complications. 2014;28(6):869-73.