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Shattering Silos: Care Coordination Cuts Diabetes Readmissions

To reduce 30-day diabetes readmissions among its diverse patient population, Truman Medical Centers (TMC) in 2010 employed a two-pronged strategy that targeted both inpatient and outpatient clinical settings.

A large portion of TMC’s patient population — which comprises 42 percent African American patients and 10 percent Hispanic/Latino patients as of FY 2009 — suffered from chronic diseases, such as diabetes, underscoring the importance of coordination among providers.

In 2010, TMC formed a corporate task force to integrate diabetes care across all departments. Inpatient strategies included designating a physician champion and developing an electronic health record (EHR) to readily identify high-risk patients in need of ancillary services. Outpatient strategies included:

  • adding a Pharm D to the diabetes clinic to enhance education and case management;
  • providing funds for the uninsured and underinsured to attend diabetes classes;
  • adding a continuity coordinator to the diabetes clinic to ensure intense management of diabetes patients; and
  • adding a scheduler to the diabetes clinic to coordinate referrals from other outpatient clinics.

TMC’s efforts had an overwhelmingly positive effect, virtually eliminating diabetes readmissions from 2010 to 2012.

Building on its success, TMC looked at the opportunity to add a certified diabetes educator on the weekends and expand patient access to healthy foods and nutritional education.

TMC said important takeaways for other hospitals include:

  • Destroying “silos” is a key to success;
  • A physician champion can encourage clinical changes among physician staff; and
  • Using chronic disease tools can align education with quality resources.


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