Telehealth-Enabled Transitional Care Across Inpatient-to-Outpatient Settings in Patients with Diabetes: A Scoping Review.

Abstract

Background: The inpatient-to-outpatient transition is a critical and vulnerable period for patients with diabetes, frequently marked by fragmented communication, incomplete follow-up, and preventable readmissions. Telehealth has emerged as a promising approach to bridge this gap; however, the design and implementation of telehealth-enabled transitional care models have not been systematically characterized.

Objective: This scoping review aimed to map existing evidence on telehealth-enabled transitional care for patients with diabetes; characterize intervention components, modalities, and target populations; and summarize reported outcomes.

Methods: Following Joanna Briggs Institute methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines, MEDLINE, CINAHL Complete, and Web of Science were searched. Eligible studies included empirical research and published protocols reporting telehealth interventions initiated during hospitalization or at discharge and continuing into outpatient or home settings.

Results: Twenty studies published between 2014 and 2025 were included. Telephone-based follow-up was the most frequently used modality, appearing in 17 of 20 studies. Nurses and nurse practitioners were the most commonly identified providers. Glycemic outcomes were more consistently improved than hospital readmission rates: 7 out of 13 studies reported significant glycated hemoglobin reductions compared with 3 out of 14 studies reporting significant readmission reductions.

Conclusions: Provider role and the social and structural context of care delivery emerged as important considerations for both clinical practice and research. Key gaps include lack of consensus on appropriate transitional duration, limited provider continuity description, limited cost-effectiveness evidence, underrepresentation of type 1 diabetes, and insufficient attention to health equity.