SHM Converge Scientific Abstract ePoster Gallery-A Spoonful of Interprofessional Medicine Will Make the Sugar Go Down

Pdf Summary

This project addresses the risks patients with diabetes face during the transition from hospital to home, where poor care coordination can lead to adverse events, delayed treatment, readmissions, and higher costs. The risk is even greater for patients with health-related social needs, such as food insecurity or limited access to medications, who are nearly twice as likely to be readmitted.<br /><br />The initiative will use Northwell Health’s existing interprofessional diabetes care teams in both inpatient and outpatient settings to improve transitions of care for this underserved population. The main goals are to improve health outcomes by lowering HbA1c levels, reduce hospital readmissions, and increase access to food and diabetes medications.<br /><br />As part of the program, patients will receive a 30-day post-discharge phone call with questions focused on their transition of care experience. The collected information will help assess the impact of the intervention on the target population.<br /><br />Expected outcomes include demonstrating the value of interprofessional transition teams for common chronic diseases like diabetes. Success will be measured by reduced HbA1c, fewer hospital readmissions and emergency room visits, and improved access to healthy food and diabetes medications. The team hopes to share the results in future research studies.

Asset Subtitle

Semie Kang

Meta Tag

Author List Rebecca H. Dougherty, Semie Kang

Category Innovations

Concept Transitional Care

Concept Readmission

Concept Diabetes Mellitus

Concept Hemoglobin A1c

Concept Hospital Discharge

Distinguished Non-Finalist

Presenter Organization Northwell Health - Long Island Jewish Medical Center

Presenting Author Semie Kang

Track Transitions of Care

Keywords

diabetes

transition of care

hospital discharge

readmission reduction

HbA1c

care coordination

food insecurity

medication access

interprofessional team

post-discharge follow-up

Transitional Care

Readmission

Diabetes Mellitus

Hemoglobin A1c

Hospital Discharge