Intensive Discharge Intervention in Diabetes

"The intervention is a multi-modal program consisting of the following:~1. Inpatient protocol for adjusting the discharge diabetes regimen;~2. Nurse practitioner discharge advocate to schedule follow-up appointments, prepare an after-hospital care plan, and patient education and counseling;~3. Inpatient pharmacist counseling (identifying and addressing previous barriers to medication adherence, performing enhanced medication reconciliation, and patient education);~4. Visiting nurse intervention after discharge;~5. Follow-up in a post-discharge clinic with the NP discharge advocate and pharmacist /certified diabetes educator within 3 days of discharge;~6. Telemonitoring of POC glucose levels to the study CDE, patient's PCP, or endocrinologist as appropriate; and~7. Follow-up with PCP or endocrinologist within 1 week of discharge."