Access to Diabetes Care for Populations Experiencing Homelessness: an Integrated Review

Using Photovoice to Explore Determinants of Health among Homeless and Unstably Housed Women

The lived experiences of homeless and unstably housed women, including their health-related priorities, are understudied in smaller metropolitan and rural communities. In this study, we partnered with a day center for women who experience homelessness in Spokane, Washington. We used Photovoice, a community-based participatory action research method, to explore the health-related concerns, needs, and behavior of women who are homeless or unstably housed. Participant-generated photographs and group interview data were analyzed using thematic analysis. Three themes were generated: "These are my supports", "I'm trying to make my health better", and "[My] choices are very limited". The themes illustrated individual, interpersonal, community, and societal strengths and vulnerabilities aligned with the social ecological model. Participants demonstrated resourcefulness, creativity, and hope as they strived toward health improvement. Trauma-informed, strengths-based approaches that respect the autonomy of homeless and unstably housed women and that amplify their voices are needed to minimize power imbalances in research, policy, and practice. This includes an imperative for healthcare and social work programs to ready graduates to deliver effective, empathic services by increasing their knowledge of social determinants of health and of the stigma faced by marginalized communities. Moreover, collaborating with these communities when designing, implementing, and evaluating services is critical.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at https://professional.diabetes.org/SOC.

Housing instability and cardiometabolic health in the United States: a narrative review of the literature

Housing instability is variably defined but generally encompasses difficulty paying rent, living in poor or overcrowded conditions, moving frequently, or spending the majority of household income on housing costs. While there is strong evidence that people experiencing homelessness (i.e., lack of regular housing) are at increased risk for cardiovascular disease, obesity, and diabetes, less is known about housing instability and health. We synthesized evidence from 42 original research studies conducted in the United States examining the association of housing instability and cardiometabolic health conditions of overweight/obesity, hypertension, diabetes, and cardiovascular disease. The included studies varied widely in their definitions and methods of measuring housing instability, but all exposure variables were related to housing cost burden, frequency of moves, living in poor or overcrowded conditions, or experiencing eviction or foreclosure, measured at either the individual household level or at a population level. We also included studies examining the impact of receipt of government rental assistance, which serves as a marker of housing instability given that its purpose is to provide affordable housing for low-income households. Overall, we found mixed but generally adverse associations between housing instability and cardiometabolic health, including higher prevalence of overweight/obesity, hypertension, diabetes, and cardiovascular disease; worse hypertension and diabetes control; and higher acute health care utilization among those with diabetes and cardiovascular disease. We propose a conceptual framework for pathways linking housing instability and cardiometabolic disease that could be targeted in future research and housing policies or programs.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Understanding the primary health care experiences of individuals who are homeless in non-traditional clinic settings

BACKGROUND

Despite the widespread implementation of Health Care for the Homeless programs that focus on comprehensive, integrated delivery systems of health care for people experiencing homelessness, engaging and retaining people experiencing homelessness in primary care remains a challenge. Few studies have looked at the primary care delivery model in non-traditional health care settings to understand the facilitators and barriers to engagement in care. The objective of our study was to explore the clinic encounters of individuals experiencing homelessness receiving care at two different sites served under a single Health Care for the Homeless program.

METHODS

Semi-structured interviews were conducted with people experiencing homelessness for an explorative qualitative study. We used convenience sampling to recruit participants who were engaged in primary care at one of two sites: a shelter clinic, n = 16, and a mobile clinic located in a church, n = 15. We then used an iterative, thematic approach to identify emergent themes and further mapped these onto the Capability-Opportunity-Motivation model.

RESULTS

Care accessibility, quality and integration were themes that were often identified by participants as being important facilitators to care. Psychological capability and capacity became important barriers to care in instances when patients had issues with memory or difficulty with perceiving psychological safety in healthcare settings. Motivation for engaging and continuing in care often came from a team of health care providers using shared decision-making with the patient to facilitate change.

CONCLUSION

To optimize health care for people experiencing homelessness, clinical interventions should: (1) utilize shared-decision making during the visit, (2) foster a sense of trust, compassion, and acceptance, (3) emphasize continuity of care, including consistent providers and staff, and (4) integrate social services into Health Care for the Homeless sites.

Developing and evaluating a SAFER model to screen for diabetes complications among people experiencing homelessness: a pilot study protocol

Background

Diabetes management combined with housing instability intersects, forcing individuals to triage competing needs and critical stressors, such as safety and shelter, with fundamental diabetes self-management tasks like attending healthcare appointments to screen for the complications of diabetes, leaving individuals overwhelmed and overburdened. We aim to address this disjuncture found within our current healthcare delivery system by providing point-of-care screening opportunities in a more patient-centered approach.

Method

We describe a pilot study of a novel clinical intervention which provides timely, comprehensive, and accessible screening for diabetes complications to people experiencing homelessness. We will assess the reach, effectiveness, adoption, implementation, and maintenance, as per the RE-AIM framework, of a SAFER model of care (i.e., screening for A1C, feet, eyes, and renal function). A trained nurse will provide this screening within a homeless shelter. During these encounters, eligible participants will be screened for microvascular complications (neuropathy, nephropathy, retinopathy) and have their A1C measured, all at the point of care, using bedside tools and novel technology. Effectiveness, our primary objective, will be evaluated using a pre-post design, by comparing the rate of completion of full microvascular screening during the study period with individuals’ own historical screening in the 2-year period prior to enrollment. The other domains of the RE-AIM framework will be assessed using process data, chart reviews, patient surveys, and qualitative semi-structured interviews with service providers and participants. This study will be conducted in a large inner-city homeless shelter within a major urban Canadian city (Calgary, Canada).

Discussion

Currently, screening for diabetes complications is often inaccessible for individuals experiencing homelessness, which places heavy burdens on individuals and, ultimately, on already strained emergency and acute care services when complications go undetected at earlier stages. The SAFER intervention will modify the current standard of care for this population in a way that is less fragmented, more person-focused, and timely, with the goal of ultimately improving the rate of screening in an acceptable fashion to identify those requiring specialist referral at earlier stages.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

Objective

The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.

Design

A realist review.

Data sources

Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019.

Eligibility criteria for selecting studies

The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.

Analysis

Inductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory.

Results

Systematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention.

Conclusions

With homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Implementation of primary care clinical pharmacy services for adults experiencing homelessness

BACKGROUND

It is estimated that on any given night in the United States, more than half a million individuals experience homelessness. Within the homeless population, chronic conditions such as diabetes, heart disease, and human immunodeficiency virus are found at rates 3-6 times higher than in the general population. Despite this, access to appropriate treatment and preventive care remains difficult for those experiencing homelessness, and many barriers exist to achieving positive health outcomes.

OBJECTIVE

The primary objective of this study was to determine the clinical impact and sustainability of implementing clinical pharmacy services in a clinic for adults experiencing homelessness.

PRACTICE DESCRIPTION

As a pilot service, a postgraduate year 2 ambulatory care pharmacy resident attended the Pedigo clinic for adults experiencing homelessness 1 half-day per week to provide independent cardiovascular risk reduction (CVRR) disease state management under a collaborative practice agreement.

PRACTICE INNOVATION

The existing CVRR model was applied at a clinic location that did not previously have clinical pharmacy services. The provision of these services was adapted to meet the unique health needs of the homeless population.

EVALUATION METHODS

The outcomes from having a clinical pharmacist in this clinic setting were retrospectively reviewed from September 2019 to March 2020.

RESULTS

During the pilot period, the pharmacist conducted 28 encounters for 14 unique patients and made a mean of 4 clinical interventions per patient encounter. A total of 124 interventions occurred, including comprehensive medication review (n = 23; 82.1%), patient education (n = 21; 75%), medication regimen optimization (n = 18; 64.3%), and tobacco cessation (n = 18; 64.3%), among several others. Clinical outcomes (glycosylated hemoglobin level, blood pressure, and weight) remained stable with pharmacist management throughout the pilot period.

CONCLUSION

The addition of a clinical pharmacist to the interdisciplinary care team for patients experiencing homelessness addresses a health care disparity and enhances the care provided to this vulnerable population.

Barriers and facilitators perceived by women while homeless and pregnant in accessing antenatal and or postnatal healthcare: A qualitative evidence synthesis

Evidence indicates that homelessness is increasing within Europe and the United States (US), particularly for women. Pregnancy rates among homeless women are exceptionally high compared to their housed counterparts and homeless women engage poorly with antenatal care. The aim of this review is to explore the barriers and facilitators perceived by homeless women, while pregnant, or within six weeks postpartum in accessing antenatal and/or postnatal healthcare. A qualitative systematic review and synthesis was conducted. Key words and search terms were derived using the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework. Titles and abstracts were screened in accordance with inclusion and exclusion criteria. The methodological quality of included papers was assessed using criteria described by the Critical Appraisal Skills Programme (CASP) with data analysis using thematic synthesis. Two primary linked themes were generated: (a) lack of person-centred care; (b) complexity of survival. At an organisational level, a fragmented health service and accessibility to the health system were barriers, and resulted in poor person-centred care. At a clinical level, attitude & treatment from healthcare providers together with health knowledge all combined to illustrate poor person-centred care as barriers to homeless women accessing antenatal/postnatal healthcare. Sub-themes associated with complexity of survival included: disillusion with life, distrust of services, competing lifestyle demands and support and relationships. The findings of this review highlight that poor engagement may be partly explained by the complex interplay between both the healthcare system (person-centred care) and the individual (complexity of survival). Future services should be delivered in a way that recognises homeless people's complex and diverse needs, and should be reconfigured in order to try to meet them, through decreasing fragmentation of health services and staff training.

Trends in Avoidable Hospitalizations for Diabetes: Experience of a Large Clinically Integrated Health Care System

Prevention quality indicators (PQIs) are used in hospital discharge data sets to identify quality of care for ambulatory care-sensitive conditions, such as diabetes. We examined the impact of clinical integration efforts on diabetes-related PQIs in a large community-based health care organization. Inpatient and observation hospitalizations from nine acute care hospitals were trended over 5 years (2012-2016). Using established technical specifications, annual hospitalizations rates were calculated for four diabetes-related PQIs: uncontrolled diabetes, short-term complications, long-term complications, and lower extremity amputations. The mean (±standard error of the mean) annual hospitalization rate for uncontrolled diabetes and short-term complications gradually increased from 1.3 ± 1.1 and 3.2 ± 2.5 per 1,000 discharges to 2.4 ± 1.7 (p < .001) and 7.1 ± 3.2 (p < .001) per 1,000 discharges, respectively. Conversely, the annual hospitalization rate for long-term complications and lower extremity amputations gradually decreased from 12.6 ± 1.1 and 88.6 ± 1.0 per 1,000 discharges to 6.5 ± 1.0 (p = .004) and 82.2 ± 1.0 per 1,000 discharges (p < .001). Trends generally persisted across payers, age, sex, and race. There was an inverse correlation between county income-per-capita and hospitalization rate for short-term complications (p = .04), long-term complications (p = .03), and lower extremity amputations (p < .001). Study limitations included use of administrative data, evolving coding practices, and ecological fallacy. Ambulatory-based efforts to optimize diabetes care can prevent long-term complications and reduce avoidable hospitalizations.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Cardiovascular Disease and Homelessness

Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.

Diabetes Care for Patients Experiencing Homelessness: Beyond Metformin and Sulfonylureas

On any given night in the United States, an estimated 553,742 people are homeless. Applying a broader definition of homelessness that includes unstably housed people, an estimated 1.5% of Americans experience homelessness in a given year. Rates of diabetes are increasing among individuals experiencing homelessness. The social, psychological, and physical challenges of homelessness not only contribute to the rate of diabetes, but also complicate management. Unstable housing, limited medical resources, food insecurity, and competing priorities are barriers to diabetes care among patients experiencing homelessness. Homeless patients with diabetes more frequently develop specific comorbidities that require special attention, such as cardiovascular disease, substance abuse, depression, and foot wounds. The Affordable Care Act gave states the option to expand Medicaid to those earning up to 138% of the federal poverty level. This addressed a gap in coverage for low-income individuals not eligible for Medicaid or employer-sponsored insurance. With increased insurance coverage, this has increased the variety of medications available to treat hyperglycemia from type 2 diabetes beyond metformin, sulfonylureas, and insulin. Several of the newer classes of medications have advantages for patients experiencing homelessness, but also have special considerations in this vulnerable patient population. This narrative review will provide a review of dipeptidyl peptidase-4 inhibitors, glucagon-like peptide agonists, sodium glucose cotransporter-2 inhibitors, and thiazolidinediones in individuals experiencing homelessness.

Making the Case for "Whole System" Approaches: Integrating Public Health and Housing

Housing conditions have been an enduring focus for public health activity throughout the modern public health era. However, the nature of the housing and health challenge has changed in response to an evolution in the understanding of the diverse factors influencing public health. Today, the traditional public health emphasis on the type and quality of housing merges with other wider determinants of health. These include the neighbourhood, community, and "place" where a house is located, but also the policies which make access to a healthy house possible and affordable for everyone. Encouragingly, these approaches to policy and action on housing have the potential to contribute to the "triple win" of health and well-being, equity, and environmental sustainability. However, more effective housing policies (and in public health in general) that adopt more systemic approaches to addressing the complex interactions between health, housing, and wider environment are needed. This paper illustrates some of the key components of the housing and health challenge in developed countries, and presents a conceptual model to co-ordinate activities that can deliver the "triple win." This is achieved by offering a perspective on how to navigate more effectively, inclusively and across sectors when identifying sustainable housing interventions.

The effect of the global financial crisis on preventable hospitalizations among the homeless in New York State

Objective Periods of economic instability may increase preventable hospitalizations because of increased barriers to accessing primary care. For underserved populations such as the homeless, these barriers may be more pronounced due to limited resources in the health care safety net. This study examined the impact of the global financial crisis of 2007-2008 on access to care for the homeless in New York State. Methods Hospitalizations for ambulatory care sensitive conditions (ACSCs) were used as a proxy measure for primary care access. Admissions for ACSCs were identified in the New York State Inpatient Database from 2006 to 2012. Hospitalization rates for ACSCs were calculated for the homeless and nonhomeless. Multivariable linear regression was used to investigate the impact of the financial crisis on hospitalization rates for ACSCs. Results The findings indicate that during the financial crisis, homeless adults had significantly higher preventable hospitalizations than nonhomeless adults, and the uninsured homeless had significantly higher preventable hospitalizations when compared to other homeless subgroups. After the financial crisis, preventable hospitalizations for the homeless stabilized but remained at higher rates than those for the nonhomeless. Conclusions These findings are important to developing health policies designed to provide effective care for underserved population such as the homeless.

Results of a metabolic health clinic at a hostel for homeless men

OBJECTIVES

People who are homeless have high mortality and morbidity, including from metabolic disorder. The aim of this study was to report on the characteristics and progress of the metabolic health of people attending a metabolic clinic at a homeless men's shelter.

METHODS

Homeless men attending the clinic were assessed by measuring their weight, height, body mass index (BMI), waist circumference, blood pressure, blood lipids, fasting blood glucose and, if indicated, HbA1c. The sample characteristics of people who attended once (one-off clients) were compared to those who attended on more than one occasion (returning clients). Changes in health status were examined among returning clients by comparing baseline results to those at their last clinic visit.

RESULTS

Baseline data were recorded on a total of 136 men, of whom 126 had a consultation with a general practitioner and at least one blood test. The 136 clients had a median BMI of 27.4 kg/m². Forty-three were obese (BMI ≥30 kg/m²), 18 had class II obesity (BMI >35 kg/m²) and seven were underweight (BMI <20 kg/m²). Sixty-five had an intervention for either a newly diagnosed condition or a change to existing medical treatment. Seventy-six returning clients were seen on an average of 2.3 further occasions. Returning clients had significant improvements in measures of metabolic health.

CONCLUSIONS

Homeless people in Sydney appear to be at a high risk of metabolic disease. The feasibility of a metabolic health clinic was demonstrated, and an encouraging improvement in some health indicators was found.