Supporting Transitions in Care for Older Adults With Type 2 Diabetes Mellitus and Obesity.

The aim of the current study was to compare outcomes for older adults with type 2 diabetes mellitus and obesity following participation in a transitional care intervention that included diabetes self-management education (DSME) and homecare. The three groups analyzed comprised an inpatient DSME plus homecare group (n = 35); an inpatient DSME only group (n = 100); and a group who received usual care (n = 45). Outcomes of interest included rehospitalization rates and hemoglobin A1C (A1C) for up to 1-year post hospital discharge. Rates of rehospitalization and A1C improved for older adults who received nurse-led inpatient DSME and homecare during transitions of care from hospital to home. Rehospitalization rates up to 90 days were decreased for the DSME plus homecare group (10%) compared to DSME only (20%) and usual care groups (26.7%) (p < 0.05). A decrease of -0.4 and -2.3 A1C units was observed for the DSME group and DSME plus homecare group, respectively, at 90 days. These results support a transitional care educational intervention for older adults with type 2 diabetes mellitus and obesity. TARGETS Older adults with type 2 diabetes mellitus and obesity. INTERVENTION DESCRIPTION Transitional care intervention including diabetes self-management education and homecare. MECHANISMS OF ACTION Inpatient diabetes education and homecare helps improve rates of rehospitalization and hemoglobin A1C during care transitions from hospital to home. OUTCOMES Rehospitalization rates, glycemic control (i.e., A1C level). [Res Gerontol Nurs. 2018; 11(2):71-81.].