This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. Transitional Case Management (TCM) is a form of case management that targets hospitalized patients in their transition from hospital-based to ambulatory care, providing support and medical management during a vulnerable time. TCM is a relatively unexplored method of care in diabetes, and has far reaching applications in the evolving US healthcare system. The primary objective is to determine if TCM will reduce use of hospital based resources such as inpatient beds and the emergency department and improve utilization of appropriate ambulatory care services such as clinic appointments. The subjects are patients with poorly controlled Type 2 Diabetes requiring admission to Harbor-UCLA. Usual care for these patients, in addition to medication adjustment and monitoring by the hospital physician, include diabetes educator consultation, diabetes education classes, and Endocrinology consultation if requested by the patient s doctor. Upon discharge, an appointment is made with a primary care clinic for follow-up. The very sickest patients are referred to Diabetes Clinic, and those requiring close follow-up are offered case management once they have been seen in clinic. Only half of the patients sent to the Harbor Diabetes clinic attend that appointment. TCM on the other hand, is case management that begins before discharge to ensure that patient makes a smooth transition to their post-discharge appointments and plan of care. For patients who consent, will be prospectively randomized if they meet criteria for poor glycemic control and utilization of the hospital and emergency department to either TCM or usual care which will serve as the control group.
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