jueves, 22 de octubre de 2009

AHRQ Innovations Exchange | Inpatient Education and Counseling Combined With Postdischarge Home Visits and Phone Calls Lead to Improved Health for Patients Who Are Obese and/or Have Diabetes


Inpatient Education and Counseling Combined With Postdischarge Home Visits and Phone Calls Lead to Improved Health for Patients Who Are Obese and/or Have Diabetes

Summary

The Hospital of the University of Pennsylvania created the Transitions in Care program as a proactive approach to bridging the gap in medical care between hospitalization and outpatient followup for patients who are obese and/or have diabetes. The program provides an initial comprehensive assessment and care transition plan, inpatient education and counseling, an ample supply of medications at discharge, and coordination of followup education and care, including home visits and phone calls. The goal is to equip patients to better manage their condition(s) after discharge through more effective blood glucose management, better adherence to prescribed medications, and lifestyle changes. The program has led to improvements in participants' physical health and to anecdotal reports from nurses of better diabetes self-management.

Evidence Rating
Moderate: The evidence consists of pre- and post-implementation comparisons of health status, as measured by the Short Form 12, along with anecdotal reports from nurses.


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AHRQ Innovations Exchange | Inpatient Education and Counseling Combined With Postdischarge Home Visits and Phone Calls Lead to Improved Health for Patients Who Are Obese and/or Have Diabetes

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