The intervention is a multi-modal program consisting of the following:

1. Inpatient protocol for adjusting the discharge diabetes regimen;
2. Nurse practitioner "discharge advocate" to schedule follow-up appointments, prepare an after-hospital care plan, and patient education and counseling;
3. Inpatient pharmacist counseling (identifying and addressing previous barriers to medication adherence, performing enhanced medication reconciliation, and patient education);
4. Visiting nurse intervention after discharge;
5. Follow-up in a post-discharge clinic with the NP discharge advocate and pharmacist /certified diabetes educator within 3 days of discharge;
6. Telemonitoring of POC glucose levels to the study CDE, patient's PCP, or endocrinologist as appropriate; and
7. Follow-up with PCP or endocrinologist within 1 week of discharge.

Patients in the control arm of this study receive usual care.

The intervention is a multi-modal program consisting of the following:

1. Inpatient protocol for adjusting the discharge diabetes regimen;
2. Nurse practitioner "discharge advocate" to schedule follow-up appointments, prepare an after-hospital care plan, and patient education and counseling;
3. Inpatient pharmacist counseling (identifying and addressing previous barriers to medication adherence, performing enhanced medication reconciliation, and patient education);
4. Visiting nurse intervention after discharge;
5. Follow-up in a post-discharge clinic with the NP discharge advocate and pharmacist /certified diabetes educator within 3 days of discharge;
6. Telemonitoring of POC glucose levels to the study CDE, patient's PCP, or endocrinologist as appropriate; and
7. Follow-up with PCP or endocrinologist within 1 week of discharge.

Cardiac medication adherence as determined by patient self report 30 days after discharge

Glycemic control as determined by change in A1c 90 days after discharge.

Emergency department visits within 30 days of discharge.