Transitioning Between Settings

Hospital admission is one of the most costly events in our health care system. As a result, there is a large focus on prevention of admissions and readmissions to hospitals. Admissions to hospitals for diabetes are considered largely preventable by many payers and are being measured under the Ambulatory Care Sensitive Conditions Program (PDF, 606 KB) . Health systems that are more tightly integrated and have attributes of excellent care coordination may see lower rates of hospital admissions for diabetes. Patients are less likely to be exposed to harm and cost in those systems.

Patients who have been hospitalized are at risk for readmission when their care is not coordinated, they are not properly educated, there is lack of attention to medication reconciliation and medication management, and there is lack of planning for subsequent patient-centered care. There is emerging research about how to decrease the likelihood for hospital readmissions. Many of these programs and efforts can be found on the Centers for Medicare & Medicaid Services website.

Patients with diabetes are at great risk for readmission to hospitals, and general efforts at readmission reduction should be applied to them. Specific processes, such as increasing use of diabetes educators, have been associated with a reduction of hospital readmissions.1,2,3