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Among homeless, compassion, compromise essential for diabetes management
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Even under ideal circumstances, diabetes is a complex condition that is not always easily managed. For the estimated 8% of the homeless population who live with diabetes, management of their disease 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, physicians 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 just extremely different, and understandably so,” Harsimran Singh, PhD, a 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 just a challenging condition to manage overall, but becomes even more complex for patients who do not have the basic essentials in life.”
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 their 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 security, 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, BS, 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.
“First, 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. “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. So, the decisions that they have to make are very challenging.”
Lack of health insurance and cost of medications are other concerns for homeless patients, as is the need for a place to conveniently store these medications, Singh said.
“Diabetes management involves something beyond lifestyle changes; it involves medications and good nutrition, and these things unfortunately aren’t cheap,” she said. “Even if they get access to medication, for example, insulin, it needs to be stored safely. If people aren’t even sure where they are going to sleep, medication storage is the least of their problems.”
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 pretty 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 reasoned that 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.”
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.
in my opinion, a significant barrier because if we just try to understand and educate ourselves about the issues this population is facing, the solution becomes much easier.”
Singh said, based on their medical training, physicians are more likely to address the clinical aspects of diabetes rather than delving deeper into the psychosocial context in which the condition is being managed.
“If you feel 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 very helpful for everybody to have a better understanding of what’s going on.” – by Jennifer Byrne
References:
Bernstein RS, et al. Am J Public Health. 2015;doi:10.2105/AJPH.2014.302330.
For more information:
Susan Cornell, BS, PharmD, CDE, can be reached at 555 W. 31st St., Alumni Hall 355, Downers Grove, IL 60515; email: scorne@midwestern.edu.
Diana L. Malkin-Washeim, PhD, can be reached at 199 Mount Eden Parkway, Bronx, NY 10457; email: dwasheim@bronxleb.org.
Harsimran Singh, PhD, can be reached at 520 Superior Ave., Suite 150, Newport Beach, CA 92663; email: harsimran.singh@hoag.org.
Disclosures: Cornell, Malkin-Washeim and Singh report no relevant disclosures.