For patients with diabetes, the days after hospital discharge can be as risky as the days leading up to admission.

Clinicians say the transition from inpatient to outpatient care remains one of the weakest links in chronic disease management — and the stakes for those suffering from diabetes are especially high.

Frequently cited studies from 2015 and 2017 showed that roughly 1 in 5 hospitalized adults with diabetes are readmitted within 30 days, often for causes that could be anticipated or prevented, such as medication errors, glucose fluctuations, and lapses in follow-up care. More recent studies suggest that those figures are still broadly accurate today, although analyses performed on Centers for Medicare & Medicaid Services claims data show readmission rates typically range from 18% to 23% for patients discharged with a principal or secondary diabetes diagnosis.

In fact, the first 90 days after discharge are especially precarious for these patients, said Kristine Batty, PhD, a diabetes nurse practitioner at the University of Maryland Baltimore Washington Medical Group. Batty said this window is especially vulnerable as patients adapt to new medication plans and self-care routines while navigating fragmented communication between inpatient and outpatient providers, all of which can quickly undermine their stability.

An Exposed Timeline

Medication can trigger issues that lead to readmission in different ways, Batty said. For one thing, she said that medication changes made during hospitalization often don’t align well with patients’ life outside the hospital, and that regimens that are overly intensive or otherwise suboptimal can lead to hypoglycemia or hyperglycemia once patients return home.

“Without timely follow-up to assess glucose trends and adjust therapy, the risk of readmission increases,” Batty said.

Carole Jakucs, MSN, RN, PHN, a certified diabetes nurse educator based in Los Angeles, said a lack of self-care training compounds the risks around medications.

“If patients take bolus insulin or glipizide during or after meals instead of beforehand, their blood glucose can spike much higher than expected,” she said. “Teaching those basics before discharge — and reinforcing them afterward — can prevent readmissions.”

This period is one of “regimen whiplash,” said Ahzam Afzal, PharmD, the co-founder and CEO of Chicago-based Puzzle Healthcare, a company that focuses on reducing postacute readmissions. He said issues like those Batty and Jakucs mentioned can escalate quickly, as well as those that often occur when supplies like insulin pens, needles, or continuous glucose monitors (CGMs) are missing or delayed due to coverage issues.

“Small gaps in access become large setbacks,” he said. “Costs, transportation, language, and caregiver barriers compound early in recovery, leaving patients susceptible to readmission risk.” 

Medication Reconciliation: Fixing a Chronic Problem 

Batty and Afzal said that medication reconciliation is one of the most error-prone transition points. They both said that incomplete or inaccurate medication lists at admission can continue to hinder a patient through their discharge, and that communication breakdowns frequently occur between hospital and outpatient teams.

According to Afzal, gaps happen at three predictable points: “at the bedside when postacute plans are finalized, at the pharmacy during coverage verification, and in the EHR [electronic health record] workflow when orders fail to transmit.” 

His company’s model uses a Meds-to-Beds approach, a workflow in which the hospital pharmacy verifies coverage, fills prescriptions, and resolves prior authorizations before discharge, so that patients leave the hospital with everything they need, having already obtained real-time coverage checks.

Regardless of how it looks in execution, Batty said pharmacists should be involved from admission onward.

“They can access external fill records, verify dosing, and flag coverage issues before discharge,” she said. “That single step reduces dangerous therapy gaps.”

Closing the Loop With Coordinated Follow-Up

Batty oversees a diabetes risk identification and discharge stratification program at the University of Maryland Baltimore Washington Medical Center that has sharply reduced readmissions.

Nurse practitioners screen inpatients and emergency department patients with diabetes to assess risk based on A1c results, medication changes, and social determinants of health. High-risk patients are then referred to a Transitional Care Center that connects them to diabetes specialists and community resources.

Designed to help patients safely bridge the gap between the hospital and home, the Transitional Care Center is staffed by a multidisciplinary team and promotes continuity by coordinating communication among the care team, the patient, and their family, and by linking hospital-based and community-based services to support ongoing recovery.

The team works with patients who frequently use the emergency department, as well as patients with complex needs, including diabetics as well as those with congestive heart failure and other conditions, connecting these patients with appropriate primary and specialty care, as well as social services, and collaborates with those providers on follow-up plans. The center also supports primary care practices that manage patients with complex needs by providing medication reconciliation, disease management education, and care planning.

Between January and October 2025, more than 300 patients participated — and overall hospital utilization dropped by 80%, with admissions down 84% within 90 days of discharge.

“Our goal is to identify at-risk patients before discharge and hand them off to a diabetes specialist who can guide medication adjustment, education, and follow-up,” Batty said. “That continuity has been transformative.”

Afzal said that rapid-touch interventions also help.

“Providing a 48-hour virtual interaction with an RN, diabetes educator, or pharmacist to confirm that medications and supplies are on hand can prevent most preventable readmissions,” he said.

Short 10- to 14-day CGM loaner programs can further catch early warning signs, he said, triggering same-day outreach for glucose excursions below 70 mg/dL or above 300 mg/dL.

Technology and Communication 

Care coordination remains the chronic Achilles’ heel, Afzal said.

“Hospital EHRs don’t speak to clinic EHRs,” Afzal said. “Medication changes, stop orders, and device updates often fail to reach the PCP [primary care physician], endocrinologist, or home health provider.” 

Afzal said that a single transition note that travels with the patient and a named care coordinator who acts as the central hub for questions and escalations can help clarify matters. Some health systems are piloting shared dashboards that alert primary care and endocrinology teams when a patient is discharged, which can knock down communications barriers, he said.

Afzal said that short-cycle metrics can also help keep partners aligned. He said tactics like monthly sharing of the 7-day contact rate, the “med-in-hand” rate, time to first titration visit, hypoglycemia calls, and emergency department returns can help teams identify where improvements are needed.

Afzal, Batty, and Jakucs reported no disclosures.