Cover Story

Challenges of diabetes management compounded among homeless

Even under ideal circumstances, diabetes is a complex condition that is not always easily managed. For the estimated 8% of the U.S. homeless population who live with diabetes, management often must take a backseat to more immediate concerns, such as finding food and shelter. For these patients, the barriers to care are myriad, from medication storage to proper nutrition to financial burdens. Therefore, when working with this population, health care providers must understand the unique challenges and often divergent priorities that are part of daily life.

“We are aware that odds are stacked against these patients, so their preferences and priorities are extremely different, and understandably so,” Harsimran Singh, PhD, health psychologist and clinical research scientist at the Mary & Dick Allen Diabetes Center at Hoag Memorial Hospital Presbyterian in Newport Beach, California, told Endocrine Today. “But, sometimes when we’re underlining problems with diabetes management in the homeless population, we overlook the fact that diabetes management is absolutely complex for our general population, as well. It’s a challenging condition to manage overall but becomes even more complex for patients who do not have the basic essentials in life.”

At NewYork-Presbyterian Hospital/Weill Cornell Medical Center, the largest health care system in New York City, Jane Jeffrie Seley, DNP, MSN, MPH, GNP, CDE, BC-ADM, CDTC, FAADE, FAAN, nurse practitioner, diabetes educator and program manager of the hospital’s glycemic control program, sees homeless patients both from the immediate area and those referred from regional hospitals for specialized care. Their many struggles, she said, stem from a lack of social supports and access to the most basic services, such as a place to safely store insulin.

Providers must work to earn the trust of this population, said Neena A. Xavier, MD, who provides diabetes care at a homeless shelter. Source: University of Alabama at Birmingham School of Health Professions. Printed with permission.

“When I try to figure out which medication regimen will work, all bets are off about whether I can get that for them,” Seley told Endocrine Today. “In New York City, the homeless get thrown out of the shelter in the morning. At 6 a.m., they’re woken up, get some breakfast and then must go out for the day. So, they must decide what to do. ‘Am I going to take my insulin with me?’ Or, if it’s really hot out, maybe they should leave it behind. They can take it with them, and something happens to it, or they leave it there, and something happens to it or it’s not there when they get back. That’s a problem.

“It’s difficult to manage them because of the lack of resources to support them when they leave,” Seley said. “That is the biggest struggle that I have.”

Obstacles to care

According to Singh, diabetes may be unique among chronic conditions in that it needs 24/7 attention, and the burden of management falls primarily on the patient. For optimal management, patients often have to juggle a variety of self-care practices, including monitoring blood glucose, taking necessary medications, and maintaining a healthy diet and physical activity. For people affected by homelessness who may be coping with stressors, such as food insecurity, extreme weather conditions and their immediate safety, keeping up with a diabetes regimen is often considered more a luxury than a necessity.

“A large part of optimal diabetes management rests on the patient, outside of the clinic,” Singh said. “If things are going generally well in our lives and we have the resources to do so, we carve out time to focus on health. When your priority is where your next meal is coming from or whether you have a place to sleep, health doesn’t feature anywhere. Good diabetes management necessitates a certain level of stability in the patient’s life, which is missing in our homeless patients.”

Susan Cornell

Susan Cornell, PharmD, CDE, associate director of experiential education and associate professor of pharmacy practice at Midwestern University Chicago College of Pharmacy, helps manage diabetes among homeless people she encounters while working at food pantries and free clinics for underserved communities. According to Cornell, she and colleagues face significant challenges both in terms of reaching at-risk populations and patient retention.

“Some of them don’t even know where to go for medical care or assistance, so that’s struggle No. 1,” Cornell told Endocrine Today. “Then it’s getting them to come back for frequent enough visits. We’re trying to manage these chronic conditions in suboptimal circumstances.”

Additionally, even patients who find the clinic, receive a diabetes diagnosis and establish a plan for management may neglect the treatment in favor of more urgent needs, Cornell said.

“When they come into a free clinic and we identify that they have diabetes or hypertension, we give them medicine, and we give them a blood glucose meter kit,” she said. Sometimes, “they will actually go and sell that because they need money for food.”

Cornell said one possible solution is to try to bring these patients in more frequently and dispense only a few days’ supply of medication at a time.

“They’re less likely to sell five tablets than they are a bottle of 30,” she said.

Access to healthy food appropriate for diabetes management is another challenge for patients who are restricted by cost or availability, according to Diana L. Malkin-Washeim, PhD, MPH, RDN, CDE, director of the nutrition and diabetes program in the population health department at BronxCare Health System, formerly called Bronx Lebanon Hospital Center, in New York.

“They’re not allowed to bring fresh produce into the shelter, from what I understand,” Malkin-Washeim told Endocrine Today. “The food at the shelters is very limited. That restricts nutrient intake.”

Additionally, some patients may use their diabetes medications or equipment to acquire a fast, inexpensive meal, Cornell said.

“If they sell a box of test strips and they get, say, $10 for it, they can get several meals at McDonald’s or Burger King,” she said. “Of course, the cheap food is not the healthy option. The decisions that they have to make are challenging.”

Lack of health insurance and cost of medications are other concerns for homeless patients, Seley said. Additionally, without a physical mailing address, Seley said, her patients cannot receive Medicaid.

“Many times, I have to figure out how I can get them what they need,” Seley said. “We usually send people home with a 1-month supply of medication ... but then what?”

Seley said the situation has forced her to get creative — often steering homeless patients toward “pop-up” programs that can meet temporary needs, such as mobile clinics that make monthly stops at shelters and churches to provide health care and medications.

Jane Jeffrie Seley

“There are all these little pockets of resources, and I learn a lot from case managers and social workers,” Seley said. “But then, whatever resources I find out about are constantly changing, and patients can’t depend on it.

“What saddens me the most is that most of these patients are willing to do whatever you ask them to do,” Seley said. “But, it becomes so impossible once they leave for them to do it. A lot of it has to do with where they can safely keep their things.”

Solutions and compromises

Oftentimes, treating diabetes in the homeless population requires striking a balance between optimal care and the patient’s daily reality. Cornell said her choice of medication for a homeless patient would depend on the patient’s specific circumstances and health profile.

“Sometimes, you have to choose less-than-optimal therapy,” she said. “For example, if I have a homeless patient with type 2 diabetes, I avoid the use of insulin, even if their HbA1c is 12%. I’m going to stick to metformin. I’m going to maybe stick to whatever I have in my closet or refrigerator at the clinic, medications that won’t have a lot of side effects for these patients considering they are living on the streets without bathroom access.”

Cornell said she often has to improvise when faced with an unexpected situation. She cited a patient who is partially homeless who presented to the clinic with pitting edema.

“His legs were huge, and the only thing we had in our closet was Lasix (furosemide), a water pill,” she said. “He lives with his sister on Saturday and Sunday, so he takes the diuretic on those days, but during the week, he only takes it Monday and Friday to avoid the side effect of frequent urination and lack of bathroom access. You have to get creative.”

Malkin-Washeim works with patients to assess the financial resources they might have.

“We explore their income,” she said. “We look at whether they have food stamps, or the Supplemental Nutrition Assistance Program (SNAP), social security or cash.

“A lot of these patients will eat out all the time and not eat within the shelter, even though they do serve food at the shelter,” she said. “The shelter food is limited, but we work with what they have. If they know what they’re usually being given at the shelter, we try to teach them the art and science of picking the right foods.”

Malkin-Washeim also teaches patients to make the most of the food options they might encounter at delis or bodegas. She suggests healthier versions of the items they might usually eat, and also asks them to instruct the deli on how to prepare the food.

“Instead of having fried chicken, maybe these patients can choose baked chicken,” she said. “Instead of having juices and sugary, sweetened beverages, maybe they can have fresh fruits. It’s a big thing to get them off these sweetened beverages because they’re so cheap.”

Working with insulin therapy

Malkin-Washeim also adapts her approach to insulin pump therapy when treating homeless populations. Given the instability of their environment, she takes special steps toward helping these patients get the treatment they need.

“If a patient is going to go forward with an insulin pump, I usually have them ship all the miscellaneous stuff for the pump itself, since it’s a $5,000 to $7,000 item, to the hospital so they can pick it up there,” she said. “That’s to protect them from somebody stealing.”

Insulin storage is another challenge facing those who are partially or entirely homeless. According to Singh, working with insulin in this population can be tricky for a variety of reasons, including medication storage and potential for hypoglycemia. Based on patient needs and available resources, health care providers may decide to use a once-daily insulin injection or insulin pens if they are more convenient. Clinics serving the homeless are also advised to store patients’ insulin and dispense one vial at a time, if possible.

“This is a good way to keep the patients engaged and promote follow-up,” Singh said.

Such follow-up visits might also be encouraged by offering the patients meal vouchers. She said using these strategies might help these patients stay out of the ED. We are more likely to be successful as providers if we engage patients by addressing their needs and concerns as much as possible,” Singh said. “We’re able to keep them longer in the program that way — we’re able to get their attention and get them motivated.”

Meeting patients where they are

Neena Agarwal Xavier, MD, assistant professor and course director for the clinical medicine course series at the University of Alabama at Birmingham (UAB), said providers must also confront a more intangible issue when working with the chronically homeless — a lack of trust.

“You can’t do chronic care where they come to you,” Xavier said. “If you want to manage diabetes care, you have to come to them and make it work for their environment. That is how you start to build trust.”

That idea was the driver behind the UAB School of Health Professions developing the Firehouse Shelter Wellness Clinic, a student-run, interprofessional clinic in Birmingham, where Xavier also serves as a volunteer medical supervisor. Xavier said the local homeless population she serves must confront several barriers to care, including a lack of transportation to the clinic, use of the ED for basic medical care and no place to store their insulin, leading to a high rate of medication spoiling.

Through several grants, Xavier and her team provide on-site care at the shelter, including full physicals, lipid and HbA1c screenings and glucose checks, as well as transportation from the shelter to the medical clinic for diabetes education and supplies.

“If they need a higher level of care, they get referrals to other free clinics or to UAB’s community clinic, where they can get free medication if needed and transportation to and from the shelter to clinic,” Xavier said. “We keep a certain number of appointments open for these patients.”

Xavier said finding grant funding for the clinic has been a collaborative effort at her institution.

“We’re always looking for new avenues for funding — service learning grants, public health grants,” Xavier said. “To start it, the grants were public health measures. Now, we’re looking at diabetes grants, too. There are avenues out there, and we have to find what best fits our mission statement.”

Xavier said the key to obtaining funding for a shelter clinic model is to start small and show sustainability.

“You don’t need huge outcomes,” Xavier said. “To say that 90% of patients reached an HbA1c of 7%, that’s just not a sustainable goal, nor is it realistic. Our first outcome was time to referral. If you ask anyone how long it took them to find an endocrinologist and then get in with them, they’ll tell you 6 to 7 months. Our time to getting help and on medication is 3 months. It’s a great turnaround. We also have 70% come to their follow-up appointment. Those are the kind of outcomes we look at.”

After the success of the student-run clinic, Xavier said others now want to be involved. At UAB, there are plans to involve the school of optometry in the initiative, possibly performing diabetic retinopathy screenings, she said.

“The hardest part is setting realistic goals, and then, second, is this idea of being siloed,” Xavier said. “If you’re able to get everyone to buy into working together, pooling resources, that increases what you can do.”

Psychosocial factors

From her perspective as a health psychologist, Singh also sees a need to further educate health care teams on the challenges and rewards of treating homeless patients and other special populations. She said she has noticed a sense of futility among some providers. Singh said, based on their medical training, physicians may be more likely to address the clinical aspects of diabetes rather than delving deeper into the psychosocial context in which the condition is being managed.

Harsimran Singh

“If your practice is in an area that does involve people who might be homeless, or are struggling with food security, just asking them a few more questions can reveal whether they’re going to need more help with their diabetes management,” she said.

Singh said for such patients, simply suggesting they lose weight and take a certain medication is not adequate. She recommends that health care providers put patients with food insecurity in touch with a social worker, even if it is one outside their own clinic.

“It’s always a great place to start, so that at least the patient knows you’re looking beyond the disease,” she said.

Malkin-Washeim agreed that it is essential that providers take the time to learn about their patients’ financial and living situations.

“Whether it’s primary care physicians or endocrinologists or any health care provider, they need to ask the demographic question. The patient might be coming in for a 3-minute visit, with the doctor just looking at blood sugars and medications, but they’re not looking at the psychosocial piece,” she said. “They’re not looking at the food security questions. I’ve tweaked my tool many times; I just added two food security questions. We also want to know if they are married, single, or if anyone knows they have diabetes.”

She said many of these patients, even if they are not entirely homeless, are marginalized and may be experiencing isolation or depression; some may be raising children in a shelter. Addressing these stresses and causes of depression is also key to providing comprehensive care to this population.

Malkin-Washeim provides group education for providers in her diabetes program, adopting a team approach. She said she is hoping to have members of her team work with the staffs at shelters to improve their approach to assisting patients with diabetes.

“The pharmacist on our team and I just had a conversation about her maybe going to shelters and doing an in-service with the staff,” she said. “We want the staff to know about who they are dealing with. There are a lot of people in these shelters with various medical problems. It would be helpful for everybody to have a better understanding of what’s going on.” – by Jennifer Byrne and Regina Schaffer

Disclosures: Cornell, Malkin-Washeim, Seley, Singh and Xavier report no relevant financial disclosures.

Click here to read the POINTCOUNTER, "What are the benefits of a diabetes screening vs. treatment clinic in the shelter setting?"

Even under ideal circumstances, diabetes is a complex condition that is not always easily managed. For the estimated 8% of the U.S. homeless population who live with diabetes, management often must take a backseat to more immediate concerns, such as finding food and shelter. For these patients, the barriers to care are myriad, from medication storage to proper nutrition to financial burdens. Therefore, when working with this population, health care providers must understand the unique challenges and often divergent priorities that are part of daily life.

“We are aware that odds are stacked against these patients, so their preferences and priorities are extremely different, and understandably so,” Harsimran Singh, PhD, health psychologist and clinical research scientist at the Mary & Dick Allen Diabetes Center at Hoag Memorial Hospital Presbyterian in Newport Beach, California, told Endocrine Today. “But, sometimes when we’re underlining problems with diabetes management in the homeless population, we overlook the fact that diabetes management is absolutely complex for our general population, as well. It’s a challenging condition to manage overall but becomes even more complex for patients who do not have the basic essentials in life.”

At NewYork-Presbyterian Hospital/Weill Cornell Medical Center, the largest health care system in New York City, Jane Jeffrie Seley, DNP, MSN, MPH, GNP, CDE, BC-ADM, CDTC, FAADE, FAAN, nurse practitioner, diabetes educator and program manager of the hospital’s glycemic control program, sees homeless patients both from the immediate area and those referred from regional hospitals for specialized care. Their many struggles, she said, stem from a lack of social supports and access to the most basic services, such as a place to safely store insulin.

Providers must work to earn the trust of this population, said Neena A. Xavier, MD, who provides diabetes care at a homeless shelter. Source: University of Alabama at Birmingham School of Health Professions. Printed with permission.

“When I try to figure out which medication regimen will work, all bets are off about whether I can get that for them,” Seley told Endocrine Today. “In New York City, the homeless get thrown out of the shelter in the morning. At 6 a.m., they’re woken up, get some breakfast and then must go out for the day. So, they must decide what to do. ‘Am I going to take my insulin with me?’ Or, if it’s really hot out, maybe they should leave it behind. They can take it with them, and something happens to it, or they leave it there, and something happens to it or it’s not there when they get back. That’s a problem.

“It’s difficult to manage them because of the lack of resources to support them when they leave,” Seley said. “That is the biggest struggle that I have.”

PAGE BREAK

Obstacles to care

According to Singh, diabetes may be unique among chronic conditions in that it needs 24/7 attention, and the burden of management falls primarily on the patient. For optimal management, patients often have to juggle a variety of self-care practices, including monitoring blood glucose, taking necessary medications, and maintaining a healthy diet and physical activity. For people affected by homelessness who may be coping with stressors, such as food insecurity, extreme weather conditions and their immediate safety, keeping up with a diabetes regimen is often considered more a luxury than a necessity.

“A large part of optimal diabetes management rests on the patient, outside of the clinic,” Singh said. “If things are going generally well in our lives and we have the resources to do so, we carve out time to focus on health. When your priority is where your next meal is coming from or whether you have a place to sleep, health doesn’t feature anywhere. Good diabetes management necessitates a certain level of stability in the patient’s life, which is missing in our homeless patients.”

Susan Cornell

Susan Cornell, PharmD, CDE, associate director of experiential education and associate professor of pharmacy practice at Midwestern University Chicago College of Pharmacy, helps manage diabetes among homeless people she encounters while working at food pantries and free clinics for underserved communities. According to Cornell, she and colleagues face significant challenges both in terms of reaching at-risk populations and patient retention.

“Some of them don’t even know where to go for medical care or assistance, so that’s struggle No. 1,” Cornell told Endocrine Today. “Then it’s getting them to come back for frequent enough visits. We’re trying to manage these chronic conditions in suboptimal circumstances.”

Additionally, even patients who find the clinic, receive a diabetes diagnosis and establish a plan for management may neglect the treatment in favor of more urgent needs, Cornell said.

“When they come into a free clinic and we identify that they have diabetes or hypertension, we give them medicine, and we give them a blood glucose meter kit,” she said. Sometimes, “they will actually go and sell that because they need money for food.”

Cornell said one possible solution is to try to bring these patients in more frequently and dispense only a few days’ supply of medication at a time.

“They’re less likely to sell five tablets than they are a bottle of 30,” she said.

PAGE BREAK

Access to healthy food appropriate for diabetes management is another challenge for patients who are restricted by cost or availability, according to Diana L. Malkin-Washeim, PhD, MPH, RDN, CDE, director of the nutrition and diabetes program in the population health department at BronxCare Health System, formerly called Bronx Lebanon Hospital Center, in New York.

“They’re not allowed to bring fresh produce into the shelter, from what I understand,” Malkin-Washeim told Endocrine Today. “The food at the shelters is very limited. That restricts nutrient intake.”

Additionally, some patients may use their diabetes medications or equipment to acquire a fast, inexpensive meal, Cornell said.

“If they sell a box of test strips and they get, say, $10 for it, they can get several meals at McDonald’s or Burger King,” she said. “Of course, the cheap food is not the healthy option. The decisions that they have to make are challenging.”

Lack of health insurance and cost of medications are other concerns for homeless patients, Seley said. Additionally, without a physical mailing address, Seley said, her patients cannot receive Medicaid.

“Many times, I have to figure out how I can get them what they need,” Seley said. “We usually send people home with a 1-month supply of medication ... but then what?”

Seley said the situation has forced her to get creative — often steering homeless patients toward “pop-up” programs that can meet temporary needs, such as mobile clinics that make monthly stops at shelters and churches to provide health care and medications.

Jane Jeffrie Seley

“There are all these little pockets of resources, and I learn a lot from case managers and social workers,” Seley said. “But then, whatever resources I find out about are constantly changing, and patients can’t depend on it.

“What saddens me the most is that most of these patients are willing to do whatever you ask them to do,” Seley said. “But, it becomes so impossible once they leave for them to do it. A lot of it has to do with where they can safely keep their things.”

Solutions and compromises

Oftentimes, treating diabetes in the homeless population requires striking a balance between optimal care and the patient’s daily reality. Cornell said her choice of medication for a homeless patient would depend on the patient’s specific circumstances and health profile.

“Sometimes, you have to choose less-than-optimal therapy,” she said. “For example, if I have a homeless patient with type 2 diabetes, I avoid the use of insulin, even if their HbA1c is 12%. I’m going to stick to metformin. I’m going to maybe stick to whatever I have in my closet or refrigerator at the clinic, medications that won’t have a lot of side effects for these patients considering they are living on the streets without bathroom access.”

PAGE BREAK

Cornell said she often has to improvise when faced with an unexpected situation. She cited a patient who is partially homeless who presented to the clinic with pitting edema.

“His legs were huge, and the only thing we had in our closet was Lasix (furosemide), a water pill,” she said. “He lives with his sister on Saturday and Sunday, so he takes the diuretic on those days, but during the week, he only takes it Monday and Friday to avoid the side effect of frequent urination and lack of bathroom access. You have to get creative.”

Malkin-Washeim works with patients to assess the financial resources they might have.

“We explore their income,” she said. “We look at whether they have food stamps, or the Supplemental Nutrition Assistance Program (SNAP), social security or cash.

“A lot of these patients will eat out all the time and not eat within the shelter, even though they do serve food at the shelter,” she said. “The shelter food is limited, but we work with what they have. If they know what they’re usually being given at the shelter, we try to teach them the art and science of picking the right foods.”

Malkin-Washeim also teaches patients to make the most of the food options they might encounter at delis or bodegas. She suggests healthier versions of the items they might usually eat, and also asks them to instruct the deli on how to prepare the food.

“Instead of having fried chicken, maybe these patients can choose baked chicken,” she said. “Instead of having juices and sugary, sweetened beverages, maybe they can have fresh fruits. It’s a big thing to get them off these sweetened beverages because they’re so cheap.”

Working with insulin therapy

Malkin-Washeim also adapts her approach to insulin pump therapy when treating homeless populations. Given the instability of their environment, she takes special steps toward helping these patients get the treatment they need.

“If a patient is going to go forward with an insulin pump, I usually have them ship all the miscellaneous stuff for the pump itself, since it’s a $5,000 to $7,000 item, to the hospital so they can pick it up there,” she said. “That’s to protect them from somebody stealing.”

Insulin storage is another challenge facing those who are partially or entirely homeless. According to Singh, working with insulin in this population can be tricky for a variety of reasons, including medication storage and potential for hypoglycemia. Based on patient needs and available resources, health care providers may decide to use a once-daily insulin injection or insulin pens if they are more convenient. Clinics serving the homeless are also advised to store patients’ insulin and dispense one vial at a time, if possible.

“This is a good way to keep the patients engaged and promote follow-up,” Singh said.

Such follow-up visits might also be encouraged by offering the patients meal vouchers. She said using these strategies might help these patients stay out of the ED. We are more likely to be successful as providers if we engage patients by addressing their needs and concerns as much as possible,” Singh said. “We’re able to keep them longer in the program that way — we’re able to get their attention and get them motivated.”

PAGE BREAK

Meeting patients where they are

Neena Agarwal Xavier, MD, assistant professor and course director for the clinical medicine course series at the University of Alabama at Birmingham (UAB), said providers must also confront a more intangible issue when working with the chronically homeless — a lack of trust.

“You can’t do chronic care where they come to you,” Xavier said. “If you want to manage diabetes care, you have to come to them and make it work for their environment. That is how you start to build trust.”

That idea was the driver behind the UAB School of Health Professions developing the Firehouse Shelter Wellness Clinic, a student-run, interprofessional clinic in Birmingham, where Xavier also serves as a volunteer medical supervisor. Xavier said the local homeless population she serves must confront several barriers to care, including a lack of transportation to the clinic, use of the ED for basic medical care and no place to store their insulin, leading to a high rate of medication spoiling.

Through several grants, Xavier and her team provide on-site care at the shelter, including full physicals, lipid and HbA1c screenings and glucose checks, as well as transportation from the shelter to the medical clinic for diabetes education and supplies.

“If they need a higher level of care, they get referrals to other free clinics or to UAB’s community clinic, where they can get free medication if needed and transportation to and from the shelter to clinic,” Xavier said. “We keep a certain number of appointments open for these patients.”

Xavier said finding grant funding for the clinic has been a collaborative effort at her institution.

“We’re always looking for new avenues for funding — service learning grants, public health grants,” Xavier said. “To start it, the grants were public health measures. Now, we’re looking at diabetes grants, too. There are avenues out there, and we have to find what best fits our mission statement.”

Xavier said the key to obtaining funding for a shelter clinic model is to start small and show sustainability.

“You don’t need huge outcomes,” Xavier said. “To say that 90% of patients reached an HbA1c of 7%, that’s just not a sustainable goal, nor is it realistic. Our first outcome was time to referral. If you ask anyone how long it took them to find an endocrinologist and then get in with them, they’ll tell you 6 to 7 months. Our time to getting help and on medication is 3 months. It’s a great turnaround. We also have 70% come to their follow-up appointment. Those are the kind of outcomes we look at.”

After the success of the student-run clinic, Xavier said others now want to be involved. At UAB, there are plans to involve the school of optometry in the initiative, possibly performing diabetic retinopathy screenings, she said.

“The hardest part is setting realistic goals, and then, second, is this idea of being siloed,” Xavier said. “If you’re able to get everyone to buy into working together, pooling resources, that increases what you can do.”

PAGE BREAK

Psychosocial factors

From her perspective as a health psychologist, Singh also sees a need to further educate health care teams on the challenges and rewards of treating homeless patients and other special populations. She said she has noticed a sense of futility among some providers. Singh said, based on their medical training, physicians may be more likely to address the clinical aspects of diabetes rather than delving deeper into the psychosocial context in which the condition is being managed.

Harsimran Singh

“If your practice is in an area that does involve people who might be homeless, or are struggling with food security, just asking them a few more questions can reveal whether they’re going to need more help with their diabetes management,” she said.

Singh said for such patients, simply suggesting they lose weight and take a certain medication is not adequate. She recommends that health care providers put patients with food insecurity in touch with a social worker, even if it is one outside their own clinic.

“It’s always a great place to start, so that at least the patient knows you’re looking beyond the disease,” she said.

Malkin-Washeim agreed that it is essential that providers take the time to learn about their patients’ financial and living situations.

“Whether it’s primary care physicians or endocrinologists or any health care provider, they need to ask the demographic question. The patient might be coming in for a 3-minute visit, with the doctor just looking at blood sugars and medications, but they’re not looking at the psychosocial piece,” she said. “They’re not looking at the food security questions. I’ve tweaked my tool many times; I just added two food security questions. We also want to know if they are married, single, or if anyone knows they have diabetes.”

She said many of these patients, even if they are not entirely homeless, are marginalized and may be experiencing isolation or depression; some may be raising children in a shelter. Addressing these stresses and causes of depression is also key to providing comprehensive care to this population.

Malkin-Washeim provides group education for providers in her diabetes program, adopting a team approach. She said she is hoping to have members of her team work with the staffs at shelters to improve their approach to assisting patients with diabetes.

“The pharmacist on our team and I just had a conversation about her maybe going to shelters and doing an in-service with the staff,” she said. “We want the staff to know about who they are dealing with. There are a lot of people in these shelters with various medical problems. It would be helpful for everybody to have a better understanding of what’s going on.” – by Jennifer Byrne and Regina Schaffer

PAGE BREAK

Disclosures: Cornell, Malkin-Washeim, Seley, Singh and Xavier report no relevant financial disclosures.

Click here to read the POINTCOUNTER, "What are the benefits of a diabetes screening vs. treatment clinic in the shelter setting?"