MON-857 - Impact of A Post-Hospital Diabetes Transition Clinic on Glycemic Control and Readmissions

Background: Diabetes mellitus (DM) is associated with increased healthcare utilization, prolonged hospitalizations, and high readmission risk, disproportionately affecting socioeconomically disadvantaged and racial and ethnic minority populations. The transition from inpatient to outpatient diabetes management represents a high-risk period, particularly for patients discharged on complex insulin regimens with limited access to endocrinology follow-up.

Objective: To evaluate the impact of a post-hospital diabetes transition clinic on glycemic control and 30-day hospital readmission rates in a high-risk, urban population.

Methods: In July 2023, an 830-bed tertiary medical center implemented a post-discharge diabetes transition clinic staffed by endocrine advanced practice providers and certified diabetes care and education specialists. High-risk patients were identified from the inpatient endocrinology service and scheduled for 1–3 post-discharge visits to optimize glycemic management and/or transition to longitudinal endocrine care. The clinic was initially launched as a half-day service and progressively expanded in visit frequency, appointment volume, and staffing over time. Demographic, clinical, and outcome data were retrospectively analyzed for patients seen between July 2023 and December 2025. Changes in HbA1c and readmission rates were assessed.

Results: A total of 437 unique patients were evaluated (mean age 55.6 years); 46.2% resided in priority zip codes and 24.5% identified as Hispanic. Type 2 diabetes accounted for 75.3% of cases. Clinic participation was associated with a statistically significant overall reduction in HbA1c (p < 0.0001). Among patients with type 2 diabetes, mean HbA1c decreased significantly from 11.04% pre-intervention to 7.4% post-intervention (p < 0.0001). Among patients residing in priority zip codes, mean HbA1c decreased from 11.2% at baseline to 7.68% post-intervention, with 80% demonstrating improvement and post-intervention values meeting institutional targets ( < 8%). Overall, the proportion of patients achieving HbA1c < 7.5% increased from 19% at admission to 63% following clinic participation. The overall 30-day readmission rate was 8.9%, with diabetes-related readmissions occurring in only 1.1% of patients, compared with institutional diabetes-related readmission rates of 8–20.5% during the same period.

Conclusions: Implementation of a post-hospital diabetes transition clinic was associated with significant improvements in glycemic control and low diabetes-related readmission rates, including substantial HbA1c reduction among patients with type 2 diabetes. The clinic’s phased expansion highlights a scalable approach to improving transitional diabetes care and promoting health equity.

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