ABSTRACT
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.
ABSTRACT
OBJECTIVES: Persons with lived experience of homelessness face many challenges in managing their diabetes, including purchasing and storing medications, procuring healthy food and accessing health-care services. Not only do these individuals have challenges in accessing primary care, they are also seen by diabetes specialists (endocrinologists, diabetes educators, foot- and eye-care specialists) less frequently. METHODS: We conducted a qualitative descriptive study using open-ended interviews of 96 health and social care providers across 5 Canadian cities (Calgary, Edmonton, Ottawa, Vancouver, Toronto). We used NVivo qualitative software to facilitate thematic analysis of the data, focussing on homelessness-related patient barriers to diabetes specialty care. RESULTS: Barriers identified included patients' competing priorities and previous negative experiences with specialists, long wait times from referral to appointment, difficulty in contacting patients and location of the clinics. Primary care providers were confident in managing diabetes in most patients and believed that patients were best served under their care. Other barriers included specialists' limited understanding of patients' complex social situations and medication coverage as well as out-of-pocket costs associated with some specialist care. Recommendations for improving access to diabetes specialty care for these medically and socially complex patients included holding diabetes specialty clinics at community health centres, providing physician-to-physician direct referrals, and selecting specialists with an interest in health of the homeless population. CONCLUSIONS: Barriers to diabetes specialty care for persons with lived experience of homelessness are due largely to the physical and social environment of the clinics. Innovative solutions may be implemented to address these challenges and improve access for this population.
