The incidence of new onset diabetes after transplant [NODAT] ranges from 2% to 53%, also Type1 [T1DM] and Type 2 [T2DM] diabetes are common in the transplant population. Immunosuppressant medications such as glucocorticoids can increase the risk of severe hyperglycemia necessitating the immediate initiation or intensification of insulin therapy to avert complications such as graft loss, infections and metabolic decompensation. Consequently, many patients will require outpatient specialized diabetes care after hospital discharge, however endocrinology wait-time is at least 2-3 months. Instead patients are commonly instructed to see their primary care provider [PCP] who may not have the resources and readiness to manage this complexity. This systemic gap constitutes unsafe patient care.

PURPOSE: (1) To improve access to specialized diabetes care for transplant recipients following discharge by utilizing the nurse practitioner [NP] role, and (2) to enhance patient safety by providing rapid assessment within 3 days of referral and transition to their PCP for ongoing management within 3 months.

METHOD: A pilot Transitional Diabetes Clinic [TDC] led by a NP working through a collaborative stream was implemented in a tertiary hospital in Canada in 2013. 144 transplant patients were enrolled over a 1-year period. Inclusion criteria included NODAT, T1DM or T2DM. Building on previous quality improvement data, outcome measures were (1) wait-time from referral to initial NP assessment and (2) transition to PCP for ongoing management within 3 months. The NP independently managed patients for up to 3 months.

RESULTS: Mean wait-time was 8.69 days. Most patients had T2DM [54.6%] followed by NODAT [36.9%] and T1DM [8.5%]. Patients spent an average of 89.98 days in the clinic. 45.7% of patients were transitioned to their PCP compared to 16.7% from earlier pilot data; 21.6% to a community endocrinologist; 12.9% to a new endocrinologist and 19.8% were referred to other providers.

CONCLUSION: The TDC model showed wait-time reduction despite exceeding the 3 day benchmark, however, this was significantly better than the current state. This model is sustainable, requires fewer resources, is innovative because it utilizes the NP expanded role of practice, provides rapid referral, offers access to the interdisciplinary team, improves patient safety, and improves collaboration between specialist and PCP. Future studies should review patient satisfaction and diabetes self-management.

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