DEMO: The patient information and names on this site are fictitious.

Patient:

CO-MORBIDITIES

ADMISSION

RISK OF 30-DAY READMISSION:
/10/10
Very high Moderate Very low
Research indicates that the following inpatient interventions may be effective in reducting the risk of early readmission.
Medication Reconciliation

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital. In situations were diabetes is not properly managed, a medication reconciliation is a necessary step in setting the patient up for success post-discharge. Medication reconciliation is a baseline intervention in most hospitals.

Endocrinologist Consultation

Most people with type 1 diabetes do see an endocrinologist, especially when they are first diagnosed, and many people with type 2 diabetes may see an endocrinologist if they are having trouble getting their diabetes under control or are developing severe complications. A endocrinologist consultation is commonplace for patients who have severe complications from their diabetes.

Additional Education

In addition to educating the patients on medication and diet, patients may need additional education on other facets of diabetes management. Some patients need help understanding how to read or change the batteries on their glucometer. Additionally, patients may need additional education on understanding the signs of hypoglycemia/hyperglycemia. These interventions are often reserved for patients who have had specific trouble monitoring their diabetes in the past.

Diabetic Management Team

In cases where the patient is at a higher risk of readmission, additional team managers may be assigned for patients with a high risk of readmission. In certain hospitals, a case manager may be assigned to each inpatient diabetes case, while in other hospitals resources may be allocated on a patient-by-patient basis. Regardless, some level of case management is a baseline intervention at most hospitals.

Dietician Consultation

A poorly managed diet is often the root cause of poorly controlled glucose levels. Patients newly diagnosed with diabetes need to be properly educated on making necessary changes to their existing diets. Even patients who have had prior consultations may benefit from a consultation as their diabetes changes over time. A dietician consultation is a baseline intervention in some hospitals, in others it is reserved for patients who have had trouble managing their diet.

Discharge Planning

Discharge planning provides a final checkpoint for the diabetic care team to ensure that the patient is in a position to successfully manage their diabetes on discharge. The discharge management team should make sure that patients have access to medications and are scheduled for any necessary outpatient interventions. Discharge planning is a baseline intervention at most hospitals.

DISCHARGE

RISK OF 30-DAY READMISSION:
/10/10
Very high Moderate Very low
Research indicates that the following outpatient interventions may be effective in reducting the risk of early readmission.
Nutritional Support/Education

In addition to inpatient dietician consultations, patients with a particularly high risk of readmission may benefit from outpatient or even in-home nutritional support. In some cases, a nutritional consultant may accompany the patient on a shopping trip to help the patient make food choices that fit with their diabetic care plan.

Family Support/Education

In many cases, a spouse or other family member may serve as a primary caregiver for a diabetic patient. These caregivers are often in the best position to help the patient manage their diabetes properly. This intervention is typically used for patients with a high risk of readmission, when the patient's family is playing a large role in their care.

Phone Check-in

A low-cost outpatient option, phone check-ins allow nursing staff to remind patients about the treatment regimen and proactively answer any questions the patient may have. A phone intervention may not be an effective option for patients not reliably reachable by phone. This intervention is relatively low cost/effort and is used for patients with moderate readmission risk at certain hospitals.

Home Care

In cases where readmission risk is very high, home care may be the only option to help a patient manage their diabetes. These interventions are often very cost intensive, and used more often in situations were the patient has mobility issues or mental illness. Home care is sometimes covered by insurance/Medicare, but patients may not know how to access it without help from the hospital.

Medication Support

The high cost of medication is often a major factor in medication noncompliance. Hospitals may consider offering counseling to patients to help them put together a plan to afford their medication. These interventions range in cost and effort but are typically used for underinsured or low-income patients.