498-P: A Patient Navigator Program for Post-discharge Diabetic Foot Care

by sugaradmin



Introduction and Objective: Diabetic foot ulcer (DFUs) are a major cause of hospitalizations, yet post-discharge care coordination remains suboptimal. Effective care organization among specialists is crucial for limb salvage. Patient navigators are an effective model for chronic disease management, but their impact on DFU care is understudied. Here, we evaluated the use of certified diabetes care and education specialist (CDCES) to improve post-hospitalization DFU care.Methods: We conducted this study at a safety-net hospital in Atlanta, GA where the historical 30-day post-hospital discharge outpatient clinic attendance rate among patients with DFUs is 55%. In December 2023, we enrolled participants hospitalized with DFUs and assigned them a CDCES who conducted weekly calls for 4 weeks. These calls consisted of diabetes management, outpatient care coordination, appointment reminders, and addressing DFU-related concerns.Results: Twelve participants were enrolled. The median (IQR) age was 53 (42-59) years; 8 (73%) were male and 8 (73%) identified as non-Hispanic Black. The median (IQR) baseline HbA1c was 8.2% (7.7-11.1). Diabetes distress scores were high [median (IQR): 2.9 (1.7-3.2)]. All participants attended a DFU-related outpatient visit within 30 days post-hospital discharge. Ten of the 12 participants used a CDCES intervention aside from appointment reminders, including setting up transportation (n=1), wound care plan clarification (n=1), antibiotic adverse effect management (n=1), rescheduling appointments (n=3), severe hyper/hypoglycemia management (n=2), and insulin education and dose – modification (n=6).Conclusion: A CDCES-led patient navigator program was associated with substantial improvement in 30 days post-discharge clinic attendance rates for patients hospitalized with DFUs and the CDCES provided comprehensive care, addressing multiple aspects of diabetes and wound management. Ongoing work will determine if this intervention improves DFU healing.

Disclosure

J. Flores: None. K. Zamudio-Coronado: None. M.C. Schechter: None. M. Fayfman: Research Support; Abbott, Dexcom, Inc. N.Y. Chaudhry: None. N. Soleimanmanesh: None. I.C. Flores: None.



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