Fluent Essays

Background Type 2 diabetes is responsible for a staggering morbidity and mortality burden. As of 2015, 9.4% percent of the United States population has diabetes; 95% of these individuals have type 2 diabetes [ 1 ]. Type 2 diabetes is associated with microvascular complications such as retinopathy, neuropathy and nephropathy, and with higher risk of macrovascular complications, including coronary artery disease, peripheral arterial disease, and stroke. Currently, type 2 diabetes is the seventh-leading cause of death in the United States [ 1 ]. Furthermore, profound racial and ethnic disparities exist in type 2 diabetes morbidity and mortality in the United States, particularly for African-Americans. Currently, 12.7% of African-Americans have type 2 diabetes [ 1 ]. African-Americans are less likely to have controlled HbA1c than non-Hispanic whites [ 2 ], are also more likely to develop retinopathy and nephropathy [ 3 ], and more likely to be hospitalized with diabetes-related complications [ 4 ]. African-Americans with type 2 diabetes also report higher levels of diabetes-related distress than non-Hispanic whites [ 5 ]. Ultimately, African-Americans have the highest diabetes-related mortality rates of any racial or ethnic group in the United States [ 3 ]. These Type 2 diabetes disparities result from a complex mix of factors. Low birth-weight and maternal-fetal stress are more common in African-American children and increase the risk of developing type 2 diabetes [ 6 ]. Higher type 2 diabetes prevalence and poorer HbA1c control may result from ethnic differences in obesity rates, body fat distribution, and glucose metabolism [ 6 ]. Cultural food practices and customs may also pose a challenge to diabetes management, such as consumption of breaded and fried meats and simple carbohydrates [ 7 ]. Additionally, African-Americans are disproportionately affected by socioeconomic factors such as poverty, poorer quality housing, lack of neighborhood spaces for physical activity, and limited access to healthy food [ 8 ]. Health care access barriers and lower quality of care also contribute to poorer diabetes outcomes in African-Americans, as can patient-provider racial discordance, perceived racial bias in medical encounters, and resulting patient mistrust in healthcare providers and systems [ 9 ]. Self-management of type 2 diabetes requires regular blood glucose monitoring, management of diet, physical activity, medications, and ongoing medical care. A key goal of diabetes self-management is the control of hemoglobin A1c (HbA1c), which is a measure of average blood glucose over several months. Poorly-controlled HbA1c is associated with microvascular and macrovascular complications [ 1 ]. The demands of managing this complex illness also affect many dimensions of quality of life (QOL), which encompasses physical, emotional and social well-being. Individuals with diabetes report lower QOL than individuals without chronic illnesses [ 10 ]. Contributors to lower QOL include diabetes-related distress; in the recent Diabetes Attitudes, Wishes and Needs second (DAWN2) study, 44.6% of those with type 2 diabetes reported distress regarding hypoglycemic events, physical health, emotional well-being, and financial strain [ 11 ]. In turn, lower QOL affects the ability to manage HbA1c and other diabetes care activities [ 12 ]. Recognizing the many challenges of managing type 2 diabetes, the American Diabetes Association (ADA) recommends that all individuals receive diabetes self-management education (DSME) at the time of a type 2 diabetes diagnosis, as well as ongoing self-management support as needed [ 13 ]. The goal of DSME is to increase an individual’s self-efficacy to manage diet, physical activity, glucose monitoring, stress management, and other necessary skills and behaviors for successful diabetes outcomes [ 13 ]. Meta-analyses have established the impact of DSME on glycemic control and QOL. In a 2002 meta-analysis, DSME participants demonstrated reductions of 0.76% in hemoglobin A1c (HbA1c) at immediate follow-up, with reductions in HbA1c attenuating to 0.24% at follow-up points 4 or more months post-intervention. The authors found three interventions measuring QOL, two of which showed QOL improvements in DSME participants; they did not combine these studies in a meta-analysis [ 14 ]. A more recent meta-analysis of group DSME programs showed HbA1c declines of 0.44% six months post-intervention, and 0.46% at 12 months. Three studies were eligible for a QOL meta-analysis; QOL changes were not significant, but the authors stipulated that the heterogeneity of the included studies was high [ 15 ]. However, neither meta-analysis examined outcomes by racial/ethnic group. Increasingly, attention has been paid to the differential impact of DSME in racial and ethnic minority groups—including African-Americans--and development of DSME that is culturally-adapted for the language, beliefs, values, and customs of particular groups. In their DSME position statement the (ADA), the American Association of Diabetes Educators (AADE) and Academy of Nutrition and Dietetics call for DSME that addresses a patient’s “cultural needs,” [ 13 ] and the AADE lists provision of “culturally competent supportive care across the lifespan” as a competency for diabetes educators [ 16 ]. Nam et al.’s 2012 meta-analysis of 12 culturally-tailored DSME interventions—four of which targeted African-Americans—showed an effect size of − 0.29 on HbA1c [ 17 ], indicating a small effect. A 2014 meta-analysis of the impact of DSME on HbA1c in ethnic minorities found an overall 0.31% HbA1c reduction in the 39 included studies; 33% of these studies included African-Americans [ 18 ]. However, these meta-analyses did not explore HbA1c results for African-Americans separately, nor did they examine QOL as an outcome. Despite the higher type 2 diabetes morbidity and mortality burden in African-Americans, no systematic reviews or meta-analyses have specifically analyzed the impact of DSME on two critical measures--HbA1c and QOL-in this population. Further, none have examined whether certain DSME characteristics, such as number of contact hours or culturally-adapted interventions, might result in better outcomes for African-Americans. The purpose of this systematic review and meta-analysis is to examine the impact of DSME in African-American adults with type 2 diabetes mellitus on HbA1c and QOL. Subgroup analyses also examined the impact of several DSME characteristics, including cultural adaptations, on HbA1c. Go to: Methods The systematic review and meta-analysis study protocol was developed prospectively and reported using Preferred Reporting for Systematic Review and Meta Analyses (PRISMA) guidelines [ 19 ]. The systematic review and meta-analysis procedures used were developed in consultation with the Cochrane Handbook for Systematic Reviews of Interventions [ 20 ]. The protocol was registered at the international prospective register of systematic reviews (PROSPERO) (ID: CRD42017057282) [ 21 ]. Search strategy The search strategy, including databases used and search terms, was developed in consultation with a medical librarian. An initial search was developed for OVID MEDLINE using keywords, medical subject (MeSH) terms and publication types based on the PICO framework (participants, comparison, intervention, and outcomes). Participants were African Americans (“African Americans,” “African Americans”[MeSH] with type 2 diabetes (“type 2 diabetes,” “type 2 diabetes mellitus,” “diabetes,” “T2DM”(type 2 diabetes mellitus), “Diabetes Mellitus”[MeSH], “Diabetes Mellitus, Type 2”[MeSH], “NIDDM” (Non-insulin dependent diabetes mellitus), or “Non-insulin dependent diabetes mellitus.”) The intervention was DSME (“diabetes self-management education,” “self management education,” “DSME,” “education.” “health education,” “diabetes education,” “Patient Education as Topic”[MeSH], or “Self Care”[MeSH]); the comparator was a control group in a randomized-controlled trial or quasi-experimental study with matched controls (“randomized controlled trial.” “controlled clinical trial,” “randomly,” “randomized,” “trial,” “control,” “groups,” or “quasi-experimental”). Outcomes were HbA1c (“HbA1c,” “A1c,” “glycemic control,” “Hemoglobin A, Glycosylated”[MeSH], or “hemoglobin A1c protein, human”[MeSH]) and QOL (“HRQL,” “QoL,” “health-related quality of life,” “Quality of Life”[MeSH]), “QOL tools OR questionnaires OR surveys,” “SF-36,” “WHOQOL,” “DQOL.” “well-being,” “psychological well-being,” or “emotional well-being”). A sample OVID MEDLINE search strategy may be found in Additional file  1 . Databases searched were OVID MEDLINE, Ovid Eric, PsycINFO, Scopus, CINAHL EBSCO, and the Cochrane Central Register of Controlled Trials. To minimize the potential omission of relevant studies, the citation lists of included studies were reviewed to identify additional studies for potential inclusion. Additionally the tables of contents for selected journals (Diabetes Care, The Diabetes Educator, Annals of Internal Medicine, and Annals of Family Medicine) were hand-checked. The search strategy also included grey literature sources such as non peer-reviewed government and nonprofit publications (the Agency for Healthcare Research and Quality, the ADA, and the Centers for Disease Control and Prevention). Inclusion and exclusion criteria All citations were reviewed against pre-determined inclusion and exclusion criteria for eligibility in the systematic review. Included study designs were randomized-controlled trials or quasi-experimental studies with a matched control group comparing DSME to usual care. The inclusion of quasi-experimental study designs was consistent with the Cochrane Consumers and Communication Review Group standards for evaluation of complex interventions [ 22 ]. “Usual care” could consist of usual primary care, assignment to a wait-list, or a minimal educational intervention. The definition of DSME was based on the ADA and AADEs’ National Standards for Diabetes Self-Management Education and Support; e.g., a program to “facilitate the development of knowledge, skills, and abilities that are required for successful self-management of diabetes” [ 13 ]. Further, the intervention needed to support at least one of the AADE7 Self-Care Behaviors: healthy eating, being active, monitoring, taking medications, problem solving, healthy coping, and reducing risks [ 23 ]. Participants were African-American adults with type 2 diabetes mellitus; to be included, interventions either needed to have exclusively African-American participants, or to report the outcomes for African-American participants separately. All potential settings (clinics, hospitals, community settings, virtual/telehealth/phone, or combinations) were included. Studies selected for the systematic review were eligible for inclusion in the HbA1c meta-analysis if they measured HbA1c mean and standard deviation both pre- and post-intervention; similarly, studies included in the systematic review were eligible for inclusion in the QOL meta-analysis if they measured QOL mean and standard deviation both pre- and post-intervention. Studies were excluded if: 1) the study population was not exclusively African-American or results for African-Americans are not reported separately; 2) the study had participants with type 1 diabetes, unless type 1 and type 2 diabetes results are reported separately; 3) the study control groups received anything other than usual care; 4) the intervention targeted providers or systems, rather than patients; 5) the intervention was a diabetes disease management or care management intervention, rather than DSME (for example, studies focusing exclusively on medical nutrition therapy or disease management); or 6) the study did not measure either HbA1c or QOL as an outcome. A study was defined as measuring QOL if it used one or more general or diabetes-specific QOL measures, which were pre-specified through a comprehensive literature search using keywords and phrases related to quality of life and frequently-used synonyms (diabetes and “quality of life” or “health-related quality of life” or “psychosocial adjustment” or “distress”). There were no study exclusions based on participant age or sex, article language, or publication date. Study selection Two independent reviewers (AC and DC) conducted the selection process through each phase of the review. All citations identified through the search were imported into a shared bibliography, and duplicate records of the same report were removed. The reviewers independently extracted information from the abstracts into structured evidence tables based on the pre-determined inclusion and exclusion criteria. Based on these criteria, they independently assessed the abstracts’ eligibility for full-text review. The two reviewers compared their results and reached consensus; a third reviewer (ML) served as a tiebreaker when needed. From this process, articles were selected for full-text review. The two reviewers independently read and assessed the full-text articles using the inclusion and exclusion criteria and met to compare results and reach consensus, with the third reviewer serving as a tiebreaker. Through this full-text review, the reviewers identified the final set of articles eligible for inclusion in the systematic review. Data extraction For the articles included in the systemic review, the two reviewers extracted further study data for inclusion in a structured evidence table. Descriptive categories included source citation, number of participants, mean participant age, percentage of participants who were African-American, and study design. Reviewers also recorded whether the intervention was group or individual-based, intervention content, presence of cultural tailoring (according to the studies’ authors), the intervention’s definition of usual care, duration, number of contact hours, provider type, DSME topics addressed, and attrition rate. The HbA1c and QOL measures used, HbA1c/QOL measurement frequency, and results were also recorded. Bias and quality appraisal Risk of bias was examined as an outcome across studies using the Cochrane Collaboration’s Risk of Bias tool, which assesses the presence of biases that pose threats to internal validity [ 24 ]. Types of bias examined in the Cochrane Risk of Bias tool included selection bias (random sequence generation and allocation concealment), performance bias (blinding participants and researchers to the intervention a participant receives), detection bias (blinding of outcome assessment from knowledge of what intervention a participant received), attrition bias, reporting bias, and other bias [ 24 ]. Studies were judged to have a low, high, or unclear risk of bias for each of these criteria. Quasi-experimental studies were automatically designated to have a high risk of bias on the random sequence generation item of the tool [ 22 ]. Two reviewers (AC and DC) independently assessed study bias and then met to compare results and reach consensus. Although assessment of publication bias was included in our protocol, due to the small number of studies in our HbA1c meta-analysis, publication bias could not be assessed. When fewer than ten studies are included in a meta-analysis, tests for forest plot asymmetry are not recommended due the low power to detect a real asymmetry [ 25 ]. The overall quality of included studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. In the GRADE system, evidence can be rated as high, moderate, low, or very low. Randomized controlled trials begin with a rating of high quality, and observational studies with a grade of low quality. Factors that can lower a quality rating include limitations in design and execution, heterogeneity (inconsistency of results), indirectness (research does not measure desired intervention or outcomes), imprecision (few patients or events), and publication bias. Factors that can increase a rating include a large magnitude of effect, a dose-response continuum, and plausible residual confounding in observational studies [ 26 ]. Two reviewers assessed study quality independently (AC and DC) and met to reach consensus. Meta-analysis All analyses were performed in Review Manager version 5.2 [ 27 ]. For studies containing both pre-and post-intervention HbA1c levels, these values were extracted as mean ± standard deviation. First, a meta-analysis was conducted to assess possible baseline HbA1c differences between intervention and control groups. Next, the mean HbA1c for both intervention and control groups at the conclusion of the intervention was transformed into a weighted mean difference (WMD), in which the contribution of each study to the mean difference is weighted by its sample size, and 95% confidence intervals (CIs) were calculated and combined in a random-effects meta-analysis. A random-effects meta-analysis is appropriate when combining studies with differences in the treatment effect [ 20 ]. A forest plot was also generated for the HbA1c WMD. Study heterogeneity was explored using Cochran’s Q and I 2, with p < .05 for Cochran’s Q and I 2 ≥ 50% indicating substantial heterogeneity [ 28 ]. In addition, several subgroup analyses were conducted for HbA1c. First examined was the impact of culturally-adapted versus non culturally-adapted DSME based on the authors’ descriptions of their interventions. Additionally, subgroup analyses were conducted based on intervention contact hours (< 10 versus ≥10), given that 10 or more contact hours has been shown to lead to better DSME outcomes; DSME provider type(s) (e.g., individual (physician, nurse, dietician, pharmacist, health educator), or multiple provider types), individual, group, or combination individual/group DSME, and attrition rate. For QOL, studies with pre-and post-intervention QOL mean ± standard deviation were eligible for inclusion in a meta-analysis. Go to: Results Fig.  1  shows the PRISMA diagram for the study selection process. A total of 352 citations were retrieved from OVID MEDLINE, Ovid Eric, PsycINFO, Scopus, CINAHL EBSCO, Cochrane Central Register of Controlled Trials, grey literature, and hand searches. After removing duplicates, 279 abstracts remained. After abstract review, 44 articles were selected for full-text review. Ultimately, 14 of those 44 articles were eligible for inclusion in the systematic review; all were from the peer-reviewed literature [ 29 – 42 ]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5956958/ Reducing Readmission Rates Among Diabetic Patients by Using Transition of Care Protocol Diabetes is a chronic condition affecting all age groups with individuals over 65 years at a higher risk (Butalia, 2020). One out of every five diabetic patients are readmitted back to the hospital within 30 days of discharge (Duke et al., 2013). Harkness (2020) reports that during transition of care, miscommunication between the providers and the ability of the new care facilities to meet the needs of patients may cause complications. Transition of care (TOC) is the transfer of a patient from one care setting to another. We use the transition of care model when discharging a patient back to the community and is a complex process requiring the collaboration of case management and care coordination departments to ensure a safe discharge. Patients who move across care settings and experience high rates of post discharge complications, readmissions or morbidity and mortality benefit from TOC (Enderlin et al., 2012). Therefore, this Doctor of Nursing Practice (DNP) project will address readmission rates reduction for patients diagnosed with diabetes mellitus (DM) by using a TOC model in managed care. The project lead will focus on the use of the TOC model in the case management and care coordination departments of a managed care organization. Background Nine and three tenth percent of the American population, representing over 30 million people, live with DM, while 28% are undiagnosed (Duke et al., 2013). 25% of hospitalized patients are diabetic with a readmission rate of 14-22%, which is higher than the rate for all hospitalized patients that is estimated to be 8.5-13.5% (Rains, 2020). Patients diagnosed with DM are more likely than those without DM to be readmitted with other complications, such as heart failure, cardiac surgery, and myocardial infarction (Rubin, 2015). Diabetes mellitus is a costly disease with direct medical cost of about $218 billion per year, besides indirect expenditure of $46 billion per year. Significant contributions to these expenditures are the readmission cases (Harkness, 2020). Studies associate lack of TOC protocol for diabetic patients with problems that hinder positive outcomes and increase readmission rates. Some challenges affecting this patient population include nonadherence to prescribed medications, lack of education on insulin injection, self-care measures, and healthy nutrition. According to Garnica (2017), lack of discharge processes causes high readmission rates among diabetic patients. Often, there is inadequate coordination between the care provider and the caregiver at home. A lack of resources in the community setting, inability for the patient to manage self-care, and a low level of health literacy of the patient and the caregiver at home contribute to recidivism. Harkness (2020) notes that instances of poor care coordination can occur between the inpatient and outpatient settings when a patient discharges from the care facility to the community. These events include lapses of communication between care providers in the inpatient and outpatient settings and include medication changes, diagnostic workups that are not done before the patient discharges, a lack of understanding of the diagnoses between the caregiver, patient and care provider, inadequate patient comprehension of medications, and insufficient coordination of the patients' follow-up needs at the time of discharge (Price, 2021). Therefore, it is necessary to create protocols using the TOC model as a framework to improve the transition process. Creating a TOC protocol will guide the discharge process to ensure proper communication between the two settings (Duke et al., 2013). A well-formulated TOC protocol is a multidisciplinary approach to better understand discharge instructions and provide the resources needed for quality home care, thus reducing the readmission rate. The TOC model ensures that the patients' caregivers, informal support, and the home health agency caregivers in the community setting receive information regarding the patient's health status and the measures to guarantee proper care at home. A patient is most vulnerable to adverse events when transitioning from the hospital to home (Harkness, 2020). Lack of care coordination and inadequate TOC protocols cost the healthcare system $46 billion a year (Harkness, 2020). Every year, DM patients' admission stay cost the United States $378 billion and readmission due to lack of TOC leads to an increase in the length of stay for patients in care settings, which further increases the financial burden. (Vandensande, 2020). Problem Statement There is a rising concern with readmission rates of DM patients. 14 percent of DM patients readmit within 30 days because of the lack of a TOC protocol to ensure that patients attain the health objectives set in the inpatient setting. Also, lack of adequate preparation before discharge leads to many patients returning to the healthcare facility because of various complications associated with DM (Rains, 2020). Implementing an appropriate TOC protocol in the case management and care coordination department, which would address the gaps in the current interdisciplinary discharge process could prevent readmissions and associated costs (Shillington & McNeil, 2021). The project site does not use the TOC model framework in the discharge process, resulting in the duplication of services and missed responsibilities that have affected patients. It has also caused an increase in readmission rates within 30 days of discharge and has increased pressure for managed care organizations to improve care coordination (Grady et al., 2021). The project lead proposes implementing discharge protocols using the TOC framework to address these gaps in best practice to improve quality patient care. Project Question In case managers and care coordinators (P), how does the use of a TOC protocol (I) compared to the current practice without TOC protocol (C) reduce the readmission rates for patients diagnosed with DM (O) within 4-5 weeks (T)? Search Methods A systematic literature search of the academic databases was conducted including the PubMed, Web of Science, Overview (SCOPUS), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) in Jay Sexter Library. These databases contain academic nursing research articles from peer-reviewed journals that are appropriate for clinical decision-making. They combine several search terms derived from the PICOT question. The search was refined by combining search terms and using the Boolean operator 'AND.' The resulting search phrases included "case managers transition of care and care quality 'care transition by coordinators' and 'self-care, DM, and DM self-care. The initial search generated over 1000 results, but not all of them applied to this search technique. Then, the search was further refined by excluding articles published before 2016 to ensure this search only included recent scientific information relevant to modern patients with DM. Eligibility for inclusion consisted of full-text articles published in English. The exclusion criteria delineated any narrative review articles, editorials, monographs, abstracts, experience reports, dissertations. These criteria reduced the search results to 113 articles, which were further appraised by reviewing the titles and abstracts. In reviewing the reference list of articles for any relevant information, 23 articles contained critical appraisal. The criteria gave three publications which extensively analyzed DM. Therefore, only the three publications from the Jay Sexter Library qualified to be included in the literature synthesis. Review Synthesis The search generated recent research articles (2016-2021) with scientific information relevant to modern patients with diabetes mellitus. Older articles could include outdated information that is irrelevant to current care settings. Combined, the articles showed the efficacy of TOC protocols by case managers and care coordinators in reducing readmission rates, improving self-care, and enhancing at-home quality care for patients with DM. Weber et al. (2017) conducted an integrative review focused on care transition between a patient's in-hospital stay and home care. The authors concluded how important improving the organization of nurses and their activities are in managed care organizations to deliver better care coordination during the transition process. Weber et al. (2017) identified five themes after the comprehensive review, including planning for discharge, health education, coordination with other health care services, and follow-up after discharge. The study showed the need for further research on TOC to help implement integrated health systems. The study has also provided evidence that promoting care coordination in managed care discharge processes is important. In a different study, Black and Duval (2019) found specific factors showing the quality of care is provided in managed care organizations. These indicators include preparing discharge care, education provided to patients and their families, continuity of care after discharge, and follow-up services. Elsewhere, Gallagher et al. (2017) focused on bridging administrative silos between various care management programs to improve the care and patient experience. The study identified various themes, including the process and communication in care provision, care transition, and patient experience. Patients with complex medical needs had a higher readmission rate. TOC reduced readmission rates for patients with diabetes and related complex medical conditions (Black & Duval, 2019). Studies have revealed a gap in care coordination that affects care delivery, including lack of social services at the community level after discharge, little and reduced access to care within community settings, and poor communication. Poor communication between patients and care professionals after discharge influences outcomes. While in the community, the patients cannot access key information regarding their health because of lack of social services in the community. The healthcare service providers, such as doctors, cannot assess patients' progress after discharge since when the patient joins the community with no social services, it becomes difficult to trace them, and assess their progress. Multiple problems develop because of absence of transition of care protocols in managed care organizations (Black & Duval, 2019). The high costs of healthcare services are greatly impacted by increased readmission rates (Black & Duval, 2019). Communication gaps between care providers and patients after discharge should be addressed to ensure proper care transition (Black & Duval, 2019). Updating the transition of care protocols will ensure that care providers, care coordination, and case management departments collaborate in taking care of the DM patients. Therefore, patients diagnosed with DM could have sufficient access to fundamental services to break this cycle and reduce readmission rates and thus reduce healthcare costs (Gallagher et al., 2017). Theme Development Diabetes is a chronic condition associated with high readmission rates after discharge from a hospital to the community setting. Some factors, such as lack of TOC protocols and diabetes-related complications, cause high readmission rates. Transition of Care (TOC) protocols entail guidelines which dictate the movement of a patient from one care to another, and in this case, from hospital care to community care. These factors encompass absence discharge processes and poor quality of care while transitioning from the hospital to the community care setting. This can negatively affect the patient's finances, insurance and payment of services. Readmissions also increase when patients transfer to the community without adequate resources, such as caregiver education and community support systems (Brumm et al., 2016). Communication Communication lapses between care providers in inpatient and outpatient settings is devastating, yet a preventable problem. Miscommunication can cause misunderstandings regarding medication changes, diagnoses, and follow-up needs in community settings. The American Diabetes Association [ADA] (2020) has provided guidelines for patients being discharged from the hospital to the community setting. The strategies from ADA guidelines include supportive clinical information systems, self-care management, and community resources and policies (ADA, 2020). Care transition is central to fulfill these ADA recommendations. Care providers are obligated to preserve the patients' safety and well-being as they transition to community care. Lack of transition of care protocols and care coordination can lead to potentially devastating patient outcomes and unnecessary healthcare spending (Shillington & McNeil, 2021). Healthcare Costs When patients readmit to the hospital, managed care organizations spend more resources to provide care. Care providers spend approximately 378 billion dollars every year because of patients' prolonged stay in managed care organizations (Shillington & McNeil, 2021). Such spending amplifies pressure on managed care organizations as they promote care coordination to enhance care delivery. Lately, lack of transition of care protocols has increased the number of DM patient's readmission, causing increased payment to providers. TOC model will help streamline healthcare delivery after discharge, which will lower readmission rates and hence lowering the costs of healthcare. The primary themes identified for the project include TOC for DM patients, discharge protocols in managed care organizations, a reduction of readmission rates, and collaboration between care coordination and case management departments. Review of Study Methods Twenty-six studies were identified, but only three studies were chosen for review. The three studies on transitions of care reviewed in the literature synthesis employed different research methodologies, a focused review (Black & Duval, 2019), integrative review (Weber et al., 2017), and descriptive longitudinal analysis (Gallagher et al., 2017). Each of these methodologies shows distinct strengths. The descriptive longitudinal analysis is a distinctive method allowing researchers to examine the same sample of participants over an extended period to determine any changes in outcomes (Caruana et al., 2015). Researchers observe the effects of treatment without interfering with variables. This method enabled Gallagher et al. to examine a cohort of 17 patients who were readmitted to the hospital within 30 days of discharge. Most of the patients readmitted several times during the study period, which allowed the researchers to determine the factors contributing to high readmission rates relative to care transition. The descriptive longitudinal analysis design was appropriate for this study because Gallagher established the correlation between care transition protocols on readmission rates by examining the cohort multiple times. In contrast, Weber et al. (2017) and Black and Duval (2019) conducted integrative reviews. Both review designs involve the systematic analysis of multiple research articles with heterogeneous methodologies to summarize underlying themes and conclusions. Integrative reviews generate reliable evidence because researchers can analyze many studies to establish gaps in literature, gauge the strength of literature, and show the need for additional research (Russell, 2005; Whittemore & Knafl, 2005). Both focused and integrative reviews involve rigorous appraisal criteria of research articles to ensure the data included in the analysis are reliable and relevant. Results from such studies are more comprehensive and credible compared to data from a single descriptive study. The current literature synthesis incorporated evidence from research articles with reliable methodologies that show how TOC protocol promotes care quality for patients with DM. Aims of the Project The DNP project is a quality improvement program aimed at reducing readmission rates for patients diagnosed with diabetes to reduce health care costs for that population. Project Objectives The main objective is to design and implement a collaborative nursing transition protocol among case management care coordination departments period. The objectives for this DNP project will be completed within four to five weeks. The objectives of this DNP project are: a. To complete the transition of care protocol for patients diagnosed with diabetes being discharged from the acute setting to community setting. b. To educate the providers on the new transition of care protocol. c. To improve the knowledge and attitudes of the providers regarding transition of care of diabetic patients from acute to community setting. d. To evaluate compliance of providers in utilizing the new protocol in practice within four to five weeks of implementation. e. To evaluate readmission rates prior to project implementation, during project implementation and then one month after the implementation. Theoretical Framework Transition is defined as changes in lives, health, relationships, and environments (Garnica, 2017). During transitions, nurses’ step in and provide a therapeutic medium helping an individual have a smooth changeover from one care setting to another. The transition theory is significant to the process that occurs when a patient is going through changes in their lives and the nurses who provide help and guidance to achieve positive outcomes (Gill & Shanta, 2020). This theory is essential for the DNP project, which focuses on the transition of care for DM patients to reduce readmission rates and healthcare costs (see Appendix A). Transition of Care protocols can decrease readmission of patients newly diagnosed with DM after they discharge from the hospital to community settings. The transition process exposes multiple risks to patients including a high possibility of readmission, poor outcomes, high care costs for patients and care providers related to readmissions (Black & Duval, 2019). Therefore, implementing TOC protocols will better meet the needs of patients diagnosed with DM by providing access to quality care and caregiver support during the transition between settings. Historical Development Nursing practice is guided by nursing theories, which describe phenomena and provide fundamental treatment principles. The transition theory that focuses on the nature of nursing practice is one of the most applied mid-range theories developed by the Egyptian theorist Afaf Ibrahim Meleis (Gill & Shanta, 2020). Meleis stated, that “nursing was always a part of her '' (Geary & Schumacher, 2019, pg number). She became the first individual in Egypt to obtain a Bachelor of Science in Nursing (BSN) degree from Syracuse University and then the first nurse to obtain a Master’s in Public Health (MPH) as well as a Doctor in Philosophy (Ph.D.) from the Egyptian University. She moved to the United States (US) and pursued her graduate education as a Rockefeller Fellow. In 1964, she received her Master of Science (MS) in Nursing (MSN) from the University of California, Master of Arts (MA) in sociology in 1966, and Doctor of Philosophy (Ph.D) in medical and psychology in 1968 (Gill & Shanta, 2020). Meleis worked as an administrator and acting instructor at the University of California in Los Angeles as an assistant professor. She later went to the University of California in San Francisco, where she spent approximately 34 years, and this became the birthplace of the transition theory (Gill & Shanta, 2020). Meleis focused her research on the transition process. The theory posits that nursing involves helping individuals going through changes that may either be physical such as illness or developmental, such as the birth of a child (Geary & Schumacher, 2019). Nurses provide primary care to patients and their families during transitions, where they attend to changes as well as the demands that are brought about by the process of transition (Harkness, 2020). Meleis investigated interventions aimed at ensuring a healthy transition. She associated an unhealthy transition with role inefficiency. The goal of healthy transition was defined as the mastery of behaviors, cues, sentiments, and symbols associated with roles and unproblematic processes (Gill & Shanta, 2020). Tenets of Transition Theory The middle-range theory of transition contains several major concepts: types and patterns of transitions, the properties of the transition experience, transition conditions, process indicators, and nursing therapeutics (Joly, 2016). Changes take various forms, such as developmental, health and illness, situational, and organizational (Kelly, 2014). Patient Engagement Patient engagement should be optimized through comprehensive and consistent efforts by the healthcare professionals to identify the outcomes of the given healthcare services, assess the patient's needs and capabilities, foster decision making concerning their plans, promote accountability for the shared care plans, and ensure trust and good relationship with the patients (Naylor et al., 2017). Caregiver Engagement The role of the caregiver is essential in the transition of care of diabetes patients. Healthcare professionals should engage the caregivers to ensure a smooth transition (Naylor et al., 2017). Here, identification of the most important outcomes of care to the caregiver is made. The caregiver’s capabilities and needs are assessed, fostering shared decision-making relating to the patient's care. The healthcare professionals should also ensure that shared accountability based on the care plans and the relationship with the caregivers is respectful (Naylor et al., 2017). The caregiver is given an important position in transition care, which will improve the outcome of the whole process of transition care. Complexity Management The complexity of management should be considered during the transition of care of diabetes patients (Naylor et al., 2017). It should be individually customized for the patients, holistic and consistent with the goals of the program. The challenge of management faced by the clinicians and the caregivers depends on the severity of the condition since it involves managing physical, emotional, and social needs (Naylor et al., 2017). By considering the complexity of the situation and identifying possible needs of the patient, it will be easy to address during the transition of care. Patient Education Patient Education should be a continuous and interactive process involving the health professionals and the patient (Naylor et al., 2017). This process is crucial because it ensures that the patient is aware that health is their responsibility, and hence it encourages the patient to make decisions towards a healthy lifestyle. Patient education also increases the patient’s adherence to medication and therapy, which promotes better health. It also reduces the adverse events resulting from the illness and promotes independence in the patient's daily living (Naylor et al., 2017). Here, the patient is given education about diabetes, the management options available, and healthy living. Caregiver Education Education of the caregiver also improves the care given to the patient once in the community. Caregivers should be taught different skills to identify and manage the worsening symptoms of diabetic patients on transition care (Naylor et al., 2017). The caregivers are also provided with access to community resources which supports the development of confidence and competencies essential in providing the patient’s needs and needs. Well-Being of the Patient and the Caregiver The wellness of the patient and the caregiver should be considered during the transition of care. The healthcare givers should acknowledge their skills. They should be respected and treated as human beings regardless of their emotional reactions, and their decisions that support the patient’s needs should be supported (Naylor et al., 2017). Care Continuity Individualized comprehensive care plans should be implemented (Naylor et al., 2017). These plans should ensure that there is access to appropriate, high-quality community patient care. The patient’s continuous access to comprehensive care fosters the health of the patient. Accountability The clinician and the whole team involved in the transition of care should assume the role of ensuring quality implementation of the transition of care (Naylor et al., 2017). There should be a partnership between clinicians and patients in developing patient care plans and ensuring their effective implementation. There should be teamwork among the different individuals involved, and there should be organizational accountability to ensure a conducive environment for the implementation of transition of care (Naylor et al., 2017). Markedly, the DNP project focuses on the health and illness transition, including the diagnosis of diabetes, a chronic condition, the recovery process, and hospital discharge. The properties of the transition experience are not fundamentally disconnected, but they are interrelated as a complex process. These properties have sub-concepts such as awareness, engagement, change and difference, time and span, and critical points and events (Joly, 2016). Awareness The awareness sub-concept involves the perception, knowledge, and recognition of a patient on the transition experience. According to Kelly (2014), a patient in transition needs to be aware of the process and expectations. In the DNP project, DM patients need to be aware of their transition to experience, which helps identify a patient's readiness for care transition. Engagement Another property of transition is engagement, and this is defined as the involvement of a person in the transition process. The awareness of an individual on the transition process influences their level of engagement (Joly, 2016). Change and differences Changes and differences are properties of transitions, where changes that individuals experience during transitions generate a sense of movement from one setting of care to another. The differences are the challenging aspects that a patient has, including unsatisfied expectations or feeling dissimilar. Nurses must ensure that a patient's comfort level is sufficient to deal with the changes and differences during the transition of care. Timespan Timespan is a property of transition that involves movement over time (Joly, 2016). DM patients have an identifiable starting point of change that is often characterized by confusion, distress, and instability (Joly, 2016). Critical points and events Nurses should step in to alleviate these adverse effects of transition on patients. Critical points and events are markers, such as diagnosing a disease, and they are used to intensifying awareness of changes or boost engagement in the transition process (Joly, 2016). Case managers need to maximize care quality for DM patients as they undergo these critical markers. The next concept is the transition condition, defined as circumstances and barriers influencing the movement of a person throughout the transition process (Garnica 2017). Common transition conditions include personal factors such as cultural beliefs and socioeconomic status, community factors like community resources available for the patient in the community setting, and societal factors such as marginalization of some communities (Garnica 2017). The theory cautions that the DM patients involved in the DNP project are also subject to these conditions. The fourth concept concerns indicators for a healthy transition process, classified into process indicators and outcome indicators (Joly, 2016). Process indicators help nurses assess DM patients and common risks to develop interventions that maximize positive outcomes. Outcome indicators help nurses to check if the transition is healthy or not (Garnica 2017). The last concept of the transition theory involves nursing therapeutics, which measure therapeutic interventions during the transition process. Project Setting The DNP project will take place in a Managed Care Organization located in the Southeast area of Dallas, Texas. The organization works with the Health and Human Services Commission (HHSC) of Texas to facilitate the patients in transitioning from the acute setting to the community setting. The organization has over 500 employees and serves more than 50,000 multiethnic Medicaid patients of all ages, however, the elderly population is the majority. Li et al. (2021) argues that there is a myriad of organizational issues in managed care settings that directly influence the high readmission rates among patients diagnosed with diabetes mellitus. Given the prevalence of readmission incidents, this an ideal setting for implementing this quality improvement project. Electronic Health Records (EHR) are used for documentation by all departments and will be utilized for the project. QNXT is the name of the system the organization uses for documentation and for processing claims from which the high readmission rate report is pulled. The high readmission rate report shows cost and the readmission rate within 30 days of discharge from the acute setting and will be the main source of data for this project. Population of Interest The populations of interest for this project are the 45 care coordinators (CC) and 15 case managers (CM) who are nurses. On …