Introduction and Objective: The organization’s transitional care center (TCC) has reduced overall rehospitalizations. Initiative evaluated whether DM nurse practitioner (NP) led post-discharge management in TCC, coupled with CHW support with SDOH barriers, reduces 90-day healthcare utilization and costs among people hospitalized with diabetes, compared to 90 days prior to index admission.Methods: In 2025, DM NP screened all inpatients with diabetes Monday-Friday and identified patients needing clinical and/or SDOH support post discharge. Risk variables assessed: admission with DKA, HHS, hypoglycemia; HgA1c >9%, new DM complication, uninsured, undocumented, no PCP. DM NP coordinated with inpatient team to secure TCC appointments. Analysis of 90-day pre/post utilization performed using hospital EMR data; healthcare costs analyzed using state designed health information exchange data.Results: Total of 239 unique patients seen by DM NP in TCC: 44% female, 24% Hispanic, 33% Black, 40% White, 3% Other. Impacts included 77% reduction in total visits, 82% reduction in admissions, and 52% reduction in costs.Conclusion: Initiative demonstrated that proactive identification of high-risk inpatients with DM, NP-delivered specialized DM care in TCC, and CHW support reduced 90-day total hospital utilization and overall healthcare costs.
K. Batty: None. A. Larbalestrier: None. K. Bocchino: None. C. Nass: Other – Scientific Education Presenter, Advisory Panel; Current; Sanofi. Other – Panel Presenter, Advisory Panel; Current; Corcept Therapeutics. Speaker’s Bureau; Current; Dexcom, Inc.
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