Diabetes mellitus is a chronic disease that requires continuous self-management to prevent complications and hospital readmissions. However, discharge planning in many hospitals is often delivered verbally and lacks structured follow-up after patients return home, which may lead to poor self-management behaviors.
This study aims to evaluate the effectiveness of a digital discharge planning intervention delivered through a mobile application to improve self-management among patients with diabetes mellitus after hospital discharge. The intervention is based on the Chronic Care Model and includes educational materials, reminders, and monitoring tools related to seven dimensions of diabetes self-management.
A randomized controlled trial with a parallel-group design will be conducted among patients with diabetes mellitus. Participants in the intervention group will receive digital discharge planning through a mobile application for 90 days after discharge, while the control group will receive standard discharge planning provided by the hospital. Primary outcomes include patient self-management behavior, while secondary outcomes include glycemic control and hospital readmission within 90 days.
Patients diagnosed with diabetes mellitus.
Age 18 years or older.
Hospitalized patients who are preparing for discharge.
Able to use a smartphone and access the mobile application.
Patients with severe complications requiring intensive care.
Patients with cognitive impairment or severe mental illness that may interfere with participation.
Patients who are unable to operate a smartphone or mobile application.
Patients who decline to participate in the study.
Parallel
Digital Discharge Planning Application
BehavioralA mobile health application designed to support diabetes self-management after hospital discharge, including education, reminders, and monitoring tools for 90 days.
Standard Discharge Planning
BehavioralParticipants receive standard discharge planning routinely provided by the hospital according to usual care procedures.
Change in diabetes self-management score
Diabetes self-management will be assessed using an adapted Indonesian version of the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire consisting of 21 items across seven domains (healthy eating, physical activity, blood glucose monitoring, medication adherence, problem solving, risk reduction, and healthy coping). Each item is scored on a 5-point Likert scale (1-5) reflecting frequency of behavior during the past 7 days. Total scores range from 21 to 105, with higher scores indicating better diabetes self-management behavior.
Change in HbA1c level
Glycemic control will be assessed by measuring glycated hemoglobin (HbA1c) levels before the intervention and at the end of the 90-day follow-up period.
Hospital readmission within 90 days
Hospital readmission due to diabetes-related complications within 90 days after discharge will be recorded from hospital records.
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