# Qualitative Assessment of a Novel Intervention to Reduce Hospital Readmission Risk Among People with Diabetes

## TL;DR

A new program called DiaTOHC was tested to help people with diabetes avoid being readmitted to the hospital after discharge.

## Contribution

The DiaTOHC intervention introduces a structured approach combining education, coordination, and follow-up to reduce diabetes-related hospital readmissions.

## Key findings

- Participants were motivated to make lifestyle changes, but those with higher A1C levels made more diabetes management changes.
- Weekly phone calls from a Navigator were effective in supporting participants during recovery.
- Participants who had fewer follow-up calls found the educational booklet more helpful.

## Abstract

To qualitatively assess a novel intervention, the Diabetes Transition of Hospital Care (DiaTOHC) Program, designed to reduce hospital readmissions within 30 days of discharge among people with diabetes.

In a separately reported randomized controlled trial of the DiaTOHC intervention, hospitalized people with diabetes were identified as high risk for 30-day hospital readmission using the Diabetes Early Readmission Risk Indicator (DERRI®). Of these, 58 participants were randomized to the intervention. After the 30-day intervention, participants and study staff completed semi-structured interviews until saturation was achieved, yielding 21 participant and 4 staff interviews. Each one underwent thematic analysis.

Four themes were identified: (1) Participants were motivated to make lifestyle changes, (2) Weekly Navigator phone calls were an effective method to support participants, (3) The intervention improved some diabetes knowledge domains but not others, and (4) Perceived lack of control was associated with readmission. Participants with baseline hemoglobin A1C (A1C) ≥8% made more changes to their diabetes management due to the intervention but were less likely to review the educational materials and had more extreme blood glucose levels. Participants who completed fewer post-discharge phone calls were more likely to find the educational booklet helpful than those who completed more calls.

Education, care coordination, and follow up are key components of the DiaTOHC Program that may improve diabetes self-management after a hospitalization and reduce readmission risk.