Transition to Home Guideline for Patients with Diabetes

Author

• Kathleen R. Burgner, Cedars SinaiFollow

Graduation Semester and Year

Summer 2026

Language

English

Document Type

DNP Project

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Kellie Kahveci

Abstract

Background: Diabetes is a leading contributor to preventable hospital readmissions. These hospital readmissions often result from fragmented discharge planning, poor care coordination, and limited post-discharge support. At a 915-bed academic medical center in Southern California, the diabetes-related readmission rate was 13.3%, compared with 11.4% among patients without diabetes. This project aimed to develop an evidence-based Transition-to-Home (TTH) guideline for hospitalized patients with diabetes and evaluate the strength of its recommendations through multidisciplinary stakeholder review.

Methods: An evidence-based guideline development project was conducted over 8 weeks. A comprehensive literature search in CINAHL, MEDLINE, PubMed, and ScienceDirect identified current evidence on transitional care for patients with diabetes. Articles published between 2020 and 2025 were graded using the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide. The evidence was synthesized and organized using the Agency for Healthcare Research and Quality National Quality Measures Clearinghouse Domain Framework. Sixteen multidisciplinary stakeholders, including registered nurses, case managers, certified diabetes educators, nursing professional development practitioners, nurse practitioners, and physicians, independently rated the recommendations using a 4-point Likert scale. Ratings were analyzed using Friedman’s Two-Way Analysis of Variance by Ranks.

Results: Five evidence-based recommendations emerged from the literature review: (1) social drivers of health screening  (SDOH) and support, (2) clinician-led care coordination, (3) medication reconciliation, (4) patient education, and (5) post-discharge telemonitoring. Stakeholder ratings demonstrated overall support for all recommendations, with mean scores exceeding 2.9 across studies. Friedman analysis revealed significant differences in stakeholder ratings among the supporting articles (χ²(9)=19.88, p=0.019), indicating variability in perceived strength of the evidence. Care coordination received the highest overall mean rank (5.98), followed by medication reconciliation (5.78), post-discharge telemonitoring (5.45), social drivers of health screening (5.34), and patient education (5.16). All interventions, however, were viewed favorably and supported inclusion in the guideline despite differences in ranking.

Conclusions: The proposed TTH guideline provides a structured, evidence-based framework for discharge planning and transitional care for hospitalized patients with diabetes. Incorporating social risk screening, care coordination, medication reconciliation, patient education, and telemonitoring may strengthen continuity of care and support organizational goals of reducing readmissions. Future implementation studies are needed to evaluate the guideline’s effect on healthcare utilization and clinical outcomes.

Keywords

Diabetes, Transition to Home, Discharge Guideline, Care Coordination, Care Transition, Transitional Care

Disciplines

Clinical and Medical Social Work | Community Health | Community Health and Preventive Medicine | Endocrine System Diseases | Family Practice Nursing | Interprofessional Education | Public Health and Community Nursing | Public Health Education and Promotion | Quality Improvement

License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Recommended Citation

Burgner, Kathleen R., "Transition to Home Guideline for Patients with Diabetes" (2026). Doctor of Nursing Practice (DNP) Scholarly Projects. 17.
https://mavmatrix.uta.edu/nursing_dnpprojects2/17