Bamberg County residents who has been diagnosed with or is at high risk for diabetes, may be eligible for a clinical research study to improve diabetes self-management and decrease hospital re-admissions.

The purpose of this study is to compare the effectiveness of three hospital discharge follow-up methods:

1. standard of care,
2. a nurse telephone intervention (care coordination and education), and
3. an in-home community health worker intervention (care coordination and education).

Inclusion Criteria:

• Bamberg County resident
• between 18 and 75 years of age
• a patient discharged from the Regional Medical Center emergency department or Regional Medical Center hospital within 72 hours prior to consent
• diagnosed with diabetes or at high risk for diabetes
• will be a Regional Medical Center patient for follow-up care
• speaks English
• has access to a phone

Stage 2 Recruitment:

• If recruitment at 3 weeks after the first patient is enrolled is < 15 or the recruitment at 12 weeks is < 45, additional inclusion criteria will include the following: Regional Medical Center outpatient or unassigned community member with uncontrolled diabetes (defined as A1C >8 or blood pressure >140/90) is uninsured or who self-reports problems with obtaining medications.

Exclusion Criteria:

• end-stage renal disease
• terminal illness (e.g., advanced cancer, end-stage chronic obstructive pulmonary disease, advanced dementia)
• incarceration
• resident in a skilled nursing home.