Caring Wisely FY 2023 Project Contest

“Home Sweet Home”: Optimal Management of Diabetes and Hyperglycemia in Endocrine Consult Patients Transitioning From Hospital to Outpatient

Proposal Status: 

PROJECT LEAD: Elizabeth Holt, MD PhD, Professor of Medicine and Surgery and Director of Inpatient Endocrinology and Transition Care, Division of Endocrinology

EXECUTIVE SPONSOR: TBA and Suneil K Koliwad, MD, PhD, Chief Division of Endocrinology and Metabolism, UCSF

ABSTRACT: Currently the UCSF Inpatient Endocrine Consult Service does not have a standardized protocol for managing diabetes in patients after discharge. Average wait for a follow up Diabetes Clinic visit at UCSF averages 32 days. The 30-day readmission rate for patients with diabetes on the medical service at UCSF is 8.2%, which is 32% higher than the national benchmark of 6.2%. With the Home Sweet Home initiative we aim to standardize and streamline the transition process from hospital to home, reduce disparities in available glucose monitoring technologies for patients at discharge, optimize communication with outpatient Diabetes Clinic providers and improve patient access to Diabetes Clinic APP's who will adjust insulin between discharge and Diabetes Clinic follow up. We aim to reduce disparities in access to Diabetes Clinic providers in the interval between discharge and first follow up visit.  We also aim to reduce the wait time substantially for outpatient follow up appointments in the Diabetes Clinic. Our goals with this initiative include improving patient safety and satisfaction and reducing risk of readmission for patients with diabetes. By being proactive about contacting all patients on insulin after discharge we aim to reduce disparities in diabetes management during the transition period caused by language barriers or lower health literacy. We expect these interventions can be generalized to other acute endocrine conditions and to other services beyond Endocrinology.

TEAM: Esther Rov-Ikpah RN-BC, MS, CDE, Meghan Talbert RN, CNS, CDE

PROBLEM: Diabetes is a chronic illness affecting 11.3% of United States adults or 37 million people nationwide, with a higher burden on those who identify as non-white or have relatively less education (A). One third of hospitalized adults have diabetes (B). Among those in the US with diabetes, approximately 30% use insulin alone or in combination with oral medications (C). Patients with diabetes have a higher rate of 30-day readmission than those without diabetes (up to 22.5 % vs 13.5%) (D), which in some cases is due to suboptimal glycemic control after discharge. Contributors to readmission in the first 30 days for all medical conditions include patients' inability to get to their follow up appointments, patients' not knowing how to reach their physician after discharge, lack of communication between inpatient and outpatient providers, and barriers related to language proficiency and health literacy (E).

TARGET: Goals of the Home Sweet Home initiative that align with the goals of Caring Wisely FY2024 include:

  • Reducing Hospital Readmissions
  • Improving Hospital Throughput and Reducing Excess Inpatient Bed Days
  • Improving Clinic Access
  • Improving Health Equity


  • Wait time to follow up Diabetes Clinic visit at UCSF after discharge from UCSF system hospitals currently averages 32 days.
  • The 30-day readmission rate for patients with diabetes on the medical service at UCSF is 8.2%, fully 32% above the national benchmark as detailed in the Abstract.
  • Glycemic control in patients immediately following discharge is often a "moving target" due to changes in contributing factors such as dosing of medications that impact blood sugars (e.g. steroids), diet, renal function, activity level and acuity of illness.
  • A supply of Freestyle Libre 2 continuous glucose monitor (CGM) sensors has already been secured by Dr. Robert Rushakoff from the manufacturer, Abbott, to offer to patients with diabetes who are followed by the endocrine consult service.  The sensor is placed at discharge by the Diabetes Education (CDE) team to allow closer monitoring of blood sugars at home.  In addition this device will alarm if glucoses are outside set parameters.  Use of this device requires the patient to download an app only compatible with a newer model smart phone or obtain the manufacturer’s reader to present the data.  The reader is not currently available free of charge, but costs $70-140 to obtain and may not be covered by insurance.  Thus patients with lower resources whose phones cannot use the reader app are unable to make use of the free CGM we offer. 
  • The inpatient Hospitalist Medicine service has a series of successful interventions for patients they discharge to prevent complications and readmission such as the Care Transition Outreach Program (CTOP) where patients are contacted after discharge to check for problems or questions. Currently there is no comparable formal system in place within the UCSF Endocrinology practice to track our patients with diabetes after discharge from inpatient medicine, surgery and OB/GYN while they await their Diabetes Clinic appointments. Currently management of our patients' glycemic control during the transition is handled on an ad hoc basis by the consult team with differences in approach from one fellow or attending to the next.
  • Patients with language, communication or health literacy barriers may be less likely to reach out for help during the transition period and may benefit from contact initiated by a Diabetes Clinic APP after discharge to ensure their glucose is in satisfactory range.
  • Given the current lack of a standardized protocol for monitoring blood sugars by the outpatient Diabetes team immediately after discharge and the month-long average wait for a follow up appointment, we postulate that hospital discharges may be delayed by the consult team to ensure glycemic control is fully optimized. We expect with a reliable standardized protocol for close follow up by the outpatient team during the transition period and with a decreased wait for follow up appointments the consult team will be willing to see patients with diabetes discharged from the hospital earlier.

With the Home Sweet Home initiative, our goal is to standardize how patients followed on the UCSF endocrine consult service for diabetes on insulin are monitored and managed as they transition to home and await their next UCSF Diabetes Clinic visit. In addition we aim to reduce the wait time for their next clinic visit from the current average of 32 days to under 14 days. We will offer the Home Sweet Home intervention from the time of discharge until the first outpatient Diabetes Clinic visit to all patients who are at risk for changes in insulin requirement while they await their follow up visit in Diabetes Clinic. This includes patients with anticipated changes in medications that impact blood sugar (e.g. tapering steroids), diet, renal function, activity level and acuity of illness. In addition patients who are new to insulin use or otherwise deemed at risk by the consult team will be offered the Home Sweet Home intervention.

I. Standardizing the transition from inpatient to outpatient care:

  1. Preparation of patient prior to discharge with information and supplies for self-monitoring of blood glucose:
    • The Freestyle Libre home glucose meter provides glucose measurements via a disposable 14-day sensor applied to the skin that samples extracellular fluid.  Results are accurate enough to inform insulin dosing in most cases.  We will continue to supply every patient who is able to use one with a free 14-day CGM sensor at discharge.
    • The CDE team will apply CGM to patient and train patient in use of CGM on the day of discharge.
    • Patients whose smart phones can serve as CGM readers will have assistance from the diabetes educators with the necessary app download and its use.  Patients who do not have a compatible smart phone will be provided a free generic Freestyle Libre 2 reader paid for through Caring Wisely funds.
    • Patients who decline a CGM will be instructed to continue fingerstick glucose monitoring at a frequency recommended by the endocrine consult team
    • Patients going home with a CGM will have it set by the CDE team to alarm for high and low blood sugars.  All patients will be provided on discharge with blood sugar parameters that should prompt an immediate call to the clinic for advice.  This information will be provided in discharge paperwork and communicated verbally by the consult team to the patient and their supports with teach-back to ensure comprehension.

 2. Brief communication between consult team and outpatient UCSF Diabetes Clinic MD and APP at the time of discharge:  A simple templated Staff Message will be sent to the new or existing outpatient diabetes provider to ensure they are aware of the patient’s admission, the reasons for admission, insulin regimen and glucose monitoring plan at discharge, date of follow up visit and any issues to address at follow up. 

3. Clinic-initiated close telephone follow up while awaiting Diabetes Clinic appointment:

    • A phone call will be initiated by the APP from the Diabetes Clinic to all patients 1-2 days after discharge to get information on their glycemic control. APP will manage any needed insulin adjustments, following up with patient over the subsequent days as needed until their scheduled clinic visit. This may be billed under code 99091 for remote interpretation of physiologic data and constitutes 1.1 wRVU.
    • During the initial phone call from the APP the patient will be reminded of their upcoming clinic visit and any barriers to attendance will be addressed.

II. Decreasing wait time to Diabetes Clinic follow up visit:  We will block out slots in all Diabetes Clinic providers' schedules that are earmarked only for hospital follow up and cannot be filled more than 14 days in advance to allow quicker follow up than currently available. These encounters may be by video, phone or in-person. These clinic slots will be designed to accommodate an total of 2 patients per week initially. The number of earmarked slots will be adjusted with time as we monitor and respond to scheduling needs.

III. Data collection: Data for glycemic control during the transition period, wait time to follow up appointment and reduction in readmission rate will be collected from pre- and post-initiation of the Home Sweet Home initiative.

- Creation of a simple smart phrase template in Epic by the Project Lead to communicate at the time of discharge with the patient's primary outpatient Diabetes Clinic MD or APP with a copy to the APP who will be reaching out to the patient 1-2 days after discharge. This message will include major reasons for hospitalization, diabetes regimen at discharge, clinic follow up date, and issues needing follow up in clinic.
- Creation of simple smart phrase in Epic by the Project Lead to provide the patient with individualized glucose parameters that should prompt a call right away to the Diabetes Clinic and the Clinic's contact information. This will also include information on how to have a language interpreter join the call. This information will be added to discharge paperwork.

$72/generic version of Freestyle Libre reader for patients who do not have compatible smart phone.

One patient per week discharged from endocrine consult service will qualify for the generic Freestyle Libre reader.

Interventions to improve clinic wait time and communication with the outpatient Diabetes team after discharge should be easily sustainable if staffing levels are kept constant or increase. Cost of the CGM kit though the Abbott program may not remain free indefinitely. Our goal in collecting data about the benefits of the Home Sweet Home initiative is in part to assist in securing funding from the Health System to continue with Home Sweet Home after the Caring Wisely budget period is over.  We expect these interventions can be generalized to other acute endocrine conditions and to other services beyond Endocrinology. 

Cost of generic Freestyle Libre 2 CGM $72

Number of patients with diabetes discharged from the consult service per week who will qualify for the free CGM reader = 1

$72/week x 52 weeks = $3744/year


A. (accessed 2/28/2023)
B. (accessed 2/28/2023)
C. (accessed 2/28/2023)
D. Ostling, S., Wyckoff, J., Ciarkowski, S.L. et al. The relationship between diabetes mellitus and 30-day readmission rates. Clin Diabetes Endocrinol 3, 3 (2017).
E. Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. 2016;176(4):484–493. doi:10.1001/jamainternmed.2015.7863