Enhancing Diabetes Self-Management Education Through Structured Assessment and Intervention at Primary Care Follow-Up
Year: 2025
Type: article
Study design: Clinical Trial
Abstract: Background Effective self-management following discharge is crucial for diabetic patients' capacity to preserve long-term health and prevent readmissions to the hospital. Even though this transitional phase is crucial, many patients suffer poor outcomes after discharge because they don't receive enough support or information during the discharge process. Purpose Implementing and assessing a structured diabetic self-management education (DSME) program at the initial primary care follow-up visit following hospital discharge was the goal of this DNP study. The objective was to decrease 30-day hospital readmission rates by enhancing patients' self-management abilities during the post-discharge follow-up. Methods A pre- and post-intervention design was utilized as a part of a quality improvement DSME project. Adults (≥18 years) with Type 2 diabetes, recently discharged (within the past 7 days) from the hospital, were recruited during their scheduled primary care follow-up appointments. At the start of the visit, participants completed a modified CTM-15 questionnaire to assess baseline self- management confidence and abilities. A one-on-one structured education session was then provided, focusing on key self-care areas such as diet, medication adherence, blood glucose monitoring, and exercise. Educational materials from the hospital’s resources were used interactively, with time for questions and hands-on demonstration. After the education, patients completed the CTM-15 again to measure any immediate improvements. Thirty days after the intervention, data were collected on whether participants had been readmitted to the hospital, to evaluate the intervention’s potential effect on readmissions. Data were analyzed using paired t-tests for the CTM-15 scores and by comparing 30-day readmission proportions pre- and post-intervention. Appropriate measures were taken to protect patient confidentiality and privacy throughout the project. Results A total of 13 participants completed the program. The average self-management score on the modified CTM-15 improved from 70.2 before the intervention to 84.0 after the intervention (SDs ≈ 3.1 for both pre- and post-scores), indicating a measurable increase in self- management capacity. Additionally, the 30-day hospital readmission rate decreased from 23.1% (3 out of 13) pre- intervention to 15.4% (2 out of 13) post-intervention. These outcomes suggested that the structured education session boosted patients’ confidence and skills in managing their diabetes, which may have contributed to fewer acute complications requiring readmission. Conclusion The results confirmed the value of systematic diabetes self-management instruction during post- hospital follow-up. Individuals who got targeted post-discharge DSME had lower 30-day readmission rates and showed increased self-care confidence. This initiative emphasized how crucial it was to use efficient teaching to ease the transition from the hospital to the home. Future projects should look into extending these interventions to larger patient populations, guaranteeing long-term follow-up assistance, and using technology-based solutions. Keywords: Diabetes self-management, CTM-15, hospital readmission, post-discharge education, transitional care
DOI: 10.7275/pq48-2k39
Author: Sinigur, Rosina
Language: English
Subfield: Endocrinology, Diabetes and Metabolism
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7106534517
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