10.0.0.0 TRAN­SI­TION FROM THE ACUTE CARE SET­TING

A struc­tured dis­charge plan tai­lored to the in­di­vid­u­al pa­tient may re­duce length of hos­pi­tal stay and read­mis­sion rates and in­crease pa­tient satisfac­tion (81). There­fore, there should be a struc­tured dis­charge plan tai­lored to each pa­tient. Dis­charge plan­ning should begin at ad­mis­sion and be up­dat­ed as pa­tient needs change.

Tran­si­tion from the acute care set­ting is a risky time for all pa­tients. Inpa­tients may be dis­charged to var­ied set­tings, in­clud­ing home (with or with­out vis­it­ing nurse ser­vices), as­sist­ed liv­ing, re­ha­bil­i­ta­tion, or skilled nurs­ing fa­cil­i­ties. For the pa­tient who is dis­charged to home or to as­sist­ed liv­ing, the op­ti­mal pro­gram will need to con­sid­er di­a­betes type and sever­i­ty, ef­fects of the pa­tient’s ill­ness on blood glu­cose lev­els, and the pa­tient’s ca­pac­i­ties and pref­er­ences. See Sec­tion 12 Older Adults” for more in­for­ma­tion.

An outpa­tient fol­low-‍up visit with the pri­ma­ry care pro­vider, en­docri­nol­o­gist, or di­a­betes ed­u­ca­tor with­in 1 month of dis­charge is ad­vised for all pa­tients hav­ing hy­per­glycemia in the hos­pi­tal. If glycemic med­i­ca­tions are changed or glu­cose con­trol is not op­ti­mal at dis­charge, an ear­li­er ap­point­ment (in 1–2 weeks) is pre­ferred, and fre­quent con­tact may be need­ed to avoid hy­per­glycemia and hy­po­glycemia. A re­cently de­scribed dis­charge al­go­rithm for glycemic med­i­ca­tion ad­just­ment based on ad­mis­sion A1C found that use of the al­go­rithm to guide treat­ment de­ci­sions re­sulted in significant im­prove­ments in the av­er­age A1C after dis­charge (6). There­fore, if an A1C from the prior 3 months is unavail­able, mea­sur­ing the A1C in all pa­tients with di­a­betes or hy­per­glycemia ad­mit­ted to the hos­pi­tal is rec­om­mend­ed.

Clear com­mu­ni­ca­tion with outpa­tient pro­viders ei­ther di­rect­ly or via hos­pi­tal dis­charge sum­maries fa­cil­i­tates safe tran­si­tions to outpa­tient care. Pro­vid­ing in­for­ma­tion re­gard­ing the cause of hy­per­glycemia (or the plan for de­ter­min­ing the cause), re­lat­ed com­pli­ca­tions and co­mor­bidi­ties, and rec­om­mend­ed treat­ments can as­sist outpa­tient pro­viders as they as­sume on­go­ing care.

The Agen­cy for Health­care Re­search and Qual­i­ty (AHRQ) rec­om­mends that, at a min­i­mum, dis­charge plans in­clude the fol­low­ing (82):

Med­i­ca­tion Rec­on­cil­i­a­tion

The pa­tient’s med­i­ca­tions must be cross-‍checked to en­sure that no chron­ic med­i­ca­tions were stopped and to en­sure the safe­ty of new pre­scrip­tions.

Pre­scrip­tions for new or changed med­i­ca­tion should be filled and re­viewed with the pa­tient and fam­i­ly at or be­fore dis­charge.

Struc­tured Dis­charge Com­mu­ni­ca­tion

Infor­ma­tion on med­i­ca­tion changes, pend­ing tests and stud­ies, and fol­low-‍up needs must be ac­cu­rate­ly and prompt­ly com­mu­ni­cat­ed to outpa­tient physi­cians.

Dis­charge sum­maries should be trans­mit­ted to the pri­ma­ry care pro­vider as soon as pos­si­ble after dis­charge.

Ap­point­ment-‍keep­ing be­hav­ior is en­hanced when the in­pa­tient team sched­ules outpa­tient med­i­cal fol­low-‍up prior to dis­charge.

It is rec­om­mend­ed that the fol­low­ing areas of knowl­edge be re­viewed and ad­dressed prior to hos­pi­tal dis­charge:

Iden­tification of the health care pro­vider who will pro­vide di­a­betes care after dis­charge.

Level of un­der­standing re­lat­ed to the di­a­betes di­ag­no­sis, self-‍mon­i­tor­ing of blood glu­cose, home blood glu­cose goals, and when to call the pro­vider.

Defini­tion, recog­ni­tion, treat­ment, and pre­ven­tion of hy­per­glycemia and hy­po­glycemia.

Infor­ma­tion on mak­ing healthy food choic­es at home and re­fer­ral to an outpa­tient reg­is­tered di­eti­tian nu­tri­tionist to guide in­di­vid­u­alization of meal plan, if need­ed.

If rel­e­vant, when and how to take blood glu­cose–low­er­ing med­i­ca­tions, in­clud­ing in­sulin ad­min­is­tra­tion.

Sick-‍day man­age­ment.

Prop­er use and dis­pos­al of nee­dles and sy­ringes.

It is im­por­tant that pa­tients be pro­vided with ap­pro­pri­ate durable med­i­cal equip­ment, med­i­ca­tions, sup­plies (e.g., blood glu­cose test strips), and pre­scrip­tions along with ap­pro­pri­ate ed­u­ca­tion at the time of dis­charge in order to avoid a po­ten­tially dan­ger­ous hia­tus in care.