Johns Hopkins University Press
Abstract

Homelessness results in barriers to effective diabetes self-management. Programs targeting individuals facing homelessness have refined strategies to address these barriers. We sought to develop a framework to characterize these strategies that could help multidisciplinary providers to better support these individuals. Semi-structured interviews were conducted with a purposive sample of health and social care providers working in diabetes or homelessness in five Canadian cities (n=96). Interview transcripts were analyzed through qualitative thematic analysis. Providers described three groups of approaches that enabled care for this population. Person-centered provider behaviours: This included tailoring care plans to accommodate individuals' situational constraints. Lower-barrier organizational structure: Providers developed specialized organizational processes to increase accessibility. Bridging to larger care systems: Strategies included providing access to support workers. Across diverse program structures, similar approaches are used to enhance diabetes care for individuals who are experiencing homelessness, highlighting tangible opportunities for mainstream services to better engage with this population.

Key words

Homelessness, diabetes, access to care, quality of care, primary care

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Cardiovascular disease is a significant contributor to mortality among those who experience homelessness.13 The prevalence of chronic diseases that lead to cardiovascular disease, such as diabetes, is comparable between housed and homeless individuals.1,3 However, people who experience homelessness are more likely to have higher glycemia and rates of diabetic ketoacidosis.47 Further, those experiencing homelessness have poorer overall health, higher rates of health care utilization, and higher rates of age-standardized mortality than the housed population.2,8,9

The reasons behind these disparities are complex. Those experiencing homelessness have numerous competing priorities that may interfere with their ability to devote the necessary time and emotional energy to diabetes self-management.4,10 This population often has poor access to primary or preventive health care services, even within health systems that provide universal health insurance.11,12 Additionally, many individuals experience significant financial barriers to accessing healthy food, medications, and diabetes supplies.4,1316 Individuals experiencing homelessness also have high rates of comorbid mental health and substance use disorders which can further complicate self-management and engagement with health care providers.2,4,9,16

Health care programs specifically designed for those who experience homelessness and their unique barriers to care can be effective in improving the health of this population.17 Work with other populations that face social and structural barriers, including groups with low socioeconomic status and racialized groups, has demonstrated that tailored diabetes services can increase patient engagement with care.18 Specifically, in a population experiencing homelessness, a small program targeted towards diabetes prevention, detection, and management was shown to increase patient awareness and empowerment, and was associated with improved glycemia.19 These findings highlight the importance of a tailored approach to diabetes care in improving outcomes for individuals who experience homelessness.

Little is known about the different ways in which diabetes care can be tailored to the needs of those who experience homelessness. Our recently completed environmental scan identified several different tailored models of care which are used by organizations that serve people with diabetes experiencing homelessness across Canada.20 These include in-shelter care; mobile care/outreach providers; pharmacy-based solutions; inner-city specialty care; and tailored diabetes groups. These innovative models of care provide templates that could be replicated by other organizations. However, in our analysis of the data from this study,20 it was clear that beyond the program specifics, there were common attitudes, principles or approaches that underpin these tailored models of care. Thus, the goal of this paper is to create a conceptual framework to better understand these central approaches, in order to offer further insight into the ways in which providers in a wide variety of clinical and social care settings may help to improve care for those with diabetes who are experiencing homelessness.

Methods

Study design

We conducted a multi-site, qualitative descriptive study, interviewing providers from programs that were tailored to address the needs of people with diabetes who are experiencing homelessness in five large Canadian urban centres. Qualitative [End Page 310] description was chosen as it can be used to comprehensively describe participant experiences while staying close to the data.21 The full details are reported elsewhere.20 This study was approved by the Research Ethics Boards of the University of Calgary and Unity Health Toronto.

Sampling and recruitment

To obtain a wide range of information, we recruited participants who had a breadth of experience in caring for individuals with diabetes and/or homelessness. This included four major categories: 1) diabetes-care professionals who focus on inner-city/homeless populations; 2) other health care providers with a specific clinical focus on inner-city/homeless populations; 3) endocrinologists/diabetes care providers (without a specific focus on homelessness); and 4) other stakeholders (e.g., front-line shelter workers, managers, social workers).

Given that there is no comprehensive listing of diabetes programs for those experiencing homelessness, we used an internet search in order to identify relevant programs in each city, using the terms "diabetes" + "homeless" + (city name). This was then broadened by searching: "health" + "homeless" + (city name). This strategy was complemented by the strategy of contacting our individual networks in each city. Furthermore, we used snowball sampling and asked each study participant to connect us with individuals at other relevant local programs. For diabetes care providers, we contacted the heads of academic divisions of endocrinology and asked them who in their respective divisions we should interview. In cases where no one was identified as having a particular interest in homelessness/poverty, we interviewed the division head or other administrative leader.

Our intent was to be as inclusive as possible, therefore we contacted all individuals identified by our searches, using publicly accessible email addresses and phone numbers.

Data collection

Data were collected using semi-structured qualitative interviews, conducted by experienced research personnel ("author 8," MD/PhD and "author 2," MPP) who had no pre-existing relationships with participants. Author 8 is a diabetologist with qualitative research expertise and author 2 has prior experience working with people experiencing homelessness. Pre-defined interview guides were created for each category of participant. These were iterative and refined after each successive interview to allow us to address the most pertinent topics. Interviews ranged from 20–90 minutes. Written informed consent was obtained. Interview recordings were transcribed verbatim by a trained professional.

Data analysis

Data were analyzed using NVivo 12 qualitative data analysis software (Doncaster, Australia). A process of inductive team-based thematic analysis was undertaken.2224 A preliminary coding template was generated by the principal investigators (author 8 and author 2), informed by literature on patient and provider factors that influence diabetes care.25 All members of the coding team ("authors 1, 2, 3, 4, 5, 6, 8") received training and instruction on qualitative analysis and the use of NVivo software.

Open coding

Initially, two interviews were coded by all members of the coding team, who were encouraged to add codes inductively throughout the process as needed. Each coder's work was reviewed in depth during a team meeting moderated by the principal investigator (author 8) who is a clinical content expert and has extensive expertise with both homelessness and qualitative data analysis. Discrepancies were resolved through discussion of multiple viewpoints. Following this meeting, another three transcripts [End Page 311] were coded by the entire team until all team members were comfortable with coding, with a similar meeting ensuing. The next 30 transcripts were coded in duplicate by one novice coder and one experienced coder with homelessness expertise (author 4 and author 2). Coding discrepancies and emerging codes were reviewed in regular team meetings after each team had completed five transcripts. The coding template was deemed complete/saturated by the end of 35 transcripts with no new codes emerging. The remainder of the transcripts were either double-coded by two novice coders or single-coded by one experienced coder.

Focused coding

Following open coding, the codes related to this area underwent focused coding (led by author 1 in consultation with author 8), through the collapsing of individual codes into themes of similar codes. Finally, the codes were considered in relation to one another to explore interrelationships between codes and themes.

Results

Of 112 individuals approached, we interviewed 96 participants from 38 organizations, representing approximately 70 different programs/services (Table 1). A large proportion of participants were nurses (24%) or physicians (31%), however a number of allied health, research and administrative personnel were also interviewed. Almost 40% of providers were in a community health center, 25% were situated in an academic center, and 16% were working in shelters.

Participants described approaches to diabetes care for people experiencing homelessness that can be understood as falling into three broad groups: (A) person-centered provider behaviours, (B) approaches that create a lower-barrier organizational structure, and (C) approaches that help patients to bridge to larger care systems. As depicted in Figure 1, these approaches were felt to create sustained engagement with care, facilitate local or immediate access to comprehensive services, and connect patients more effectively to services offered by the broader health system. Representative quotations are provided in the text and Box 1.

Person-centered provider behaviours

Providers' descriptions of working with people experiencing homelessness illustrated that engaging this population in diabetes care is facilitated by taking a person-centered approach. Providers tried to offer more person-centered care in two ways: 1) focusing on building relationships; and 2) delivering care that was tailored to individuals' situational constraints.

Relationships

Strong patient-provider or client-provider relationships were described as a pre-requisite to effective diabetes care. Providers said that many of their patients or clients lacked trust in the health care system (often due to previous negative experiences) and that investing time to build relationships and earn trust created opportunities to provide care: "The trust is the most vital component … [it's the] relationship-building and sometimes it takes a little while, right … I think a lot of things have been broken in relationships with this population of clients." (Dietitian 1)

Strong relationships can also help patients or clients maintain longer-term engagement with health care services because trust with one provider can act as a gateway to meeting other trusted providers. Providers said that patients were more willing to [End Page 312]

Table 1. PARTICIPANTS' DEMOGRAPHICSa
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Table 1.

PARTICIPANTS' DEMOGRAPHICSa

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Figure 1. Schematic depicting the conceptual framework of approaches to providing tailored diabetes care for individuals experiencing homelessness.
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Figure 1.

Schematic depicting the conceptual framework of approaches to providing tailored diabetes care for individuals experiencing homelessness.

attend appointments with specialists or other care providers when introduced by a trusted source.

Tailoring care to patients' situational constraints

Providers recognized the importance of delivering care that was tailored to individuals' unique situations. As one provider described this, it involved "… making sure that the recommendations, approaches are actually meaningful … tailored to those specific challenges that people are facing when they are homeless." (Administrative Personnel 1) This tailoring was achieved using three broad strategies: 1) a harm reduction approach, 2) a holistic perspective, and 3) building self-efficacy. These approaches helped providers to create care plans and recommendations that could be acted on by clients who had limited resources and many competing priorities and challenges.

Some providers endorsed a harm reduction approach, in which the focus of care was shifted away from meeting mainstream clinical guidelines or targets, and shifted towards making small, manageable adjustments that were aligned with best practices in [End Page 314]

. SELECTED QUOTATIONS ILLUSTRATING APPROACHES TO DIABETES CAREa

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diabetes care and could be successfully implemented within the context of the patients' constraints. For example, providers discussed choosing non-insulin medications that were easier to take and store or accepting higher blood sugar levels in patients who were at risk of hypoglycemia due to food insecurity. Other providers used harm reduction approaches while working with patients on reducing consumption of sugar-sweetened beverages, controlling portion sizes when eating high carbohydrate meals at shelters, and choosing better foods from limited options.

Providers also adopted a holistic perspective on diabetes management. This type of approach focused on helping individuals develop stability in other areas of their lives or address social factors that were contributing to their health to facilitate diabetes management (such as housing needs and mental health concerns). [End Page 316]

Finally, providers used techniques to help their patients or clients build self-efficacy so that diabetes management could be seen as a manageable task rather than yet another priority in competition with so many others. With this approach, providers re-framed diabetes management in a way that was motivating or aligned with individuals' other life goals. Providers helped patients develop a practical understanding of diabetes, and worked to help them set goals and develop strategies for initiating changes, empowering patients to take ownership of their care:

We take the approach that diabetes can help you feel like you have more control in your life and we try to encourage them to think that way. If you have to stay in a shelter, you have to stay in a shelter, you don't get a choice. You get that mat over there, you know. But, you can make a choice of what you eat. You can make a choice to walk. You can make a choice to let somebody look at your feet and address your wounds.

—Nurse 1

Lower-barrier organizational structure

A lower-barrier organizational structure helped facilitate access to health care services. Programs created these lower-barrier environments by implementing specialized processes; providing access to multidisciplinary health services and social supports; and building incentives into programing to facilitate engagement.

Specialized processes

Specialized processes that facilitated access to care included: scheduling and staffing flexibility; providing care opportunistically; using adaptable communication systems; providing supportive, safe, and inclusive spaces; and providing outreach-based services.

Scheduling and staffing flexibility can decrease barriers to care. As an example, many programs avoid penalizing patients for missing appointments or arriving late. Further, some providers described making a concerted effort to see patients the same day even if they arrived after their scheduled appointment: "If an individual shows up even if they are extremely late for their appointments, we have policies in which they are able to see the duty doctor." (Nurse 3) Other programs integrated drop-in or walk-in appointments into their weekly schedule, so patients were able to see a provider at their convenience: "we have walk-in times … In order to be truly accessible you have to go there and be accommodating when people don't show up for appointments." (Family Doctor 1) Some programs scheduled longer appointments so that multiple issues could be addressed in a single visit. Providers also described booking appointments with different providers together to reduce the number of trips a patient needed to make. Further, many programs set up their staffing so that diabetes educators could join appointments with a primary care provider whenever a diabetes-specific concern was identified. Some programs were able to offer phone or video visits to make attending appointments easier.

Providers also discussed the fact that it was important to provide care in an opportunistic fashion—whenever the providers were able to engage patients or clients without making them wait for appointments. Many programs provide diabetes care when patients were in touch for other reasons such as prescription refills, vaccinations, medication dispensing, or assessments for social support programs. One provider also described a program that provided primary care services through a free veterinary clinic. Other [End Page 317] providers described collaborating with community pharmacies to deliver opportunistic diabetes care (https://www.frontiersin.org/articles/10.3389/fcdhc.2022.1087751/full).

Getting in touch with patients or clients was frequently seen as a challenge, so some programs used alternative methods to keep in contact with patients and increase the likelihood of follow-up. For example, some used message boards at shelters or social media to communicate with patients or clients. One provider at a community health centre said, "… they go on [social] media, like on Facebook and remind them of the appointments … because of that, people will come more often" (Endocrinologist 1) One shelter program described attaching appointment reminders to clients' profiles in their organization's information management systems, which would alert the staff when clients signed in to stay the night. Staff could then remind the client of their upcoming appointment. Additionally, pharmacists were often useful points of contact.

Programs also attempted to create supportive, safe, and inclusive spaces to help people feel more comfortable attending appointments. Some programs helped individuals feel safe by situating specialized care within a familiar clinical environment. One provider said, "They like having it like at a community health centre where it could be anyone goes there, you know, and so they are like, oh yeah, yeah, like I'm not this segregated little group." (Nurse Practitioner 1) Providers in one program described how their more lenient policies around behaviour in the clinic allowed more potential patients to attend. Other programs had formal training or policies that codified values of equity and inclusion: "We have a low-barrier non-judgemental environment. So our clerical staff have been trained around customer service, and understanding that regardless what an individual looks like and how they present to the clinic that you treat them the same, with dignity." (Nurse 4) Several programs tailored to Indigenous clients incorporated traditional cultural practices or teachings. Additionally, some programs were able to make special accommodations in their physical spaces. For example, one program had a monitored area for patients to leave shopping carts and others allowed patients to bring pets to the clinic.

Finally, some programs and providers worked to meet individuals' needs by providing care through outreach, outside of a traditional health care setting. In some cases, outreach was regularly provided in fixed locations such as shelters by bringing diabetes specialists and others to provide care in proximity to patients. Other outreach activities were mobile, and providers in these programs circulated through inner-city locations to make themselves available to patients wherever they might be likely to spend time. The outreach approach helped providers to engage with potential new clients and was often useful for initiating relationships and trust-building. Outreach also allowed providers to meet individuals on their terms, and some felt that this helped people feel more motivated to engage with care: "we are meeting them on their grounds, on their time schedule and they have more of a say in their health care and I think if you allow individuals to have more choice … I think they are more willing to step in and take more self-management of their care." (Nurse 2)

Multidisciplinary services

Many programs provided access to multidisciplinary health and social care services in one location (a "one-stop shop"). This type of service [End Page 318] provision reduced barriers and allowed providers to help address many complex intersecting needs.26

Often, programs provided these health and social services in partnership with other organizations. In other cases, programs employed and trained providers who had an extended scope of practice, or implemented policies that allowed individual providers to work outside of their traditional scope. Finally, some programs provided important services that might not typically be available through primary care providers, such as on-site pharmacy, and phlebotomy or laboratory services.

Incentives

Programs also tailored their organizational structure by incorporating incentives such as food, opportunities for social interaction, and small rewards into their programs. As one provider described it, "I don't know what it is they get out of coming here, but they keep coming back and so they are getting something out of it and I think it's the social support piece that they get from each other and from me." (Nurse Practitioner 2) Other incentives included material goods or supports to help people meet their basic needs including clothing and footwear, diabetes supplies and medications, and physical activity supports (i.e., gym passes). Providers felt that these incentives helped motivate patients to attend appointments and programming, and may have helped patients to make diabetes care a priority despite competing demands.

Bridging to larger care systems

Providers identified the fact that many patients struggled to independently navigate the services available within mainstream health and social care systems. As a result, programs employed strategies to support navigation, such as 1) helping patients to connect with primary care providers, 2) providing tailored referrals to meet patients' health and social needs, and 3) using specialized support or outreach workers to help with navigation. Providers felt that these navigation supports helped prevent patients from being lost to follow-up and supported them in accessing the full range of care that they needed.

Connecting patients with primary care

Providers in acute or specialty care programs discussed the importance of identifying whether patients have primary care providers; if this was not the case, many took steps to get patients connected to have their long-term and broader health needs looked after.

Specialized referrals for health and social care

If multidisciplinary services were not available on-site, providers helped patients to access these services by making referrals for specialized diabetes, health, or social care. Importantly, many providers highlighted the importance of referring to programs or other providers that were accessible to patients or clients and were well adapted or sensitive to their unique needs and situation. For example, one provider said, "We try to pick places that are kind to our clients. If we have lots of issues or if they are going to be very sensitive about missed appointments, then that's not a good fit." (Nurse 5)

Support workers

Providers also identified the fact that many patients struggled to follow through on referrals and appointments because of a lack of comfort seeing new providers in unfamiliar locations. In response, many programs had designated support or outreach workers who provided reminders, accompanied patients to appointments, advocated for them, and otherwise provided personalized support to help patients build or maintain a connection with providers. One provider said, "her role is really to go [End Page 319] with people and do that really warm handoff and walk through that initial intake at [Health Centre] or at the hospitals, to make it really easy for people and make it really safe." (Nurse 6)

Discussion

Despite differences in program specifics, there are key commonalities in the way that providers approach diabetes care for people who are experiencing homelessness, illustrated by our framework. In patient or client interactions, providers described taking a person-centred approach to care. At the organizational level, they discussed approaches and structures that helped reduce barriers to care. Finally, providers described helping patients or clients to navigate the larger health care and social assistance systems.

Our framework provides a comprehensive understanding of the tailored approaches that are used by organizations who care for this population. The accounts of these providers demonstrate that there are a variety of specific ways in which these approaches can be applied. We hope that this framework can serve as a guide that health and social care providers and program managers can use to adapt their practices to better engage patients or clients and make care more accessible.

There is little work published specifically on the tailoring of diabetes care for people experiencing homelessness.17,18,19,26 However, the approaches to diabetes care that we have described here align well with interventions described for the provision of primary care to this population, including the management of other chronic conditions. For example, navigation support, outreach, expanded hours, facilitated appointment booking and reminders, practicing trauma-informed care, drop-in services, transportation services, role expansion or task shifting, and a one-stop shop model have been described in relation to improving access to primary care for this population.27,28 Additionally, many interventions that have been successful in improving the health and well-being of people experiencing homelessness have centred on providing rapid access to housing and treatment for substance use and mental health disorders.2933 Although these services did not emerge as sole approaches to care within our study, the providers that we interviewed did highlight the importance of providing access to multidisciplinary services including social supports to address the upstream determinants of adverse diabetes outcomes.

Case management has also been described extensively in the literature on providing care to people experiencing homelessness.2933 It has been shown to have positive impacts on housing, substance use, and mental health among those experiencing homelessness and is included in a recently published clinical practice guideline for providing care to homeless or vulnerably housed people.2934 Additionally, a review of interventions for tailoring diabetes care to socially disadvantaged populations found that interventions that included one-on-one, individualized care may be beneficial.18 Further, case management may improve health literacy and self-efficacy among those experiencing homelessness.35 The approaches that emerged from our data for helping to navigate care systems rest on many of the same principles as case management.34,35

The approaches to care that we have described also align with previous reports [End Page 320] on the preferences of people who use these services, who have stated that trust and empowerment were both integral components of health system interventions.36,37

The harm reduction approach to diabetes self-management that we have reported here has not been commonly reported elsewhere. Harm reduction for substance use has been shown to be effective in helping patients stabilize their consumption, reduce high-risk use behaviours, and in some cases reduce mortality.38,39 Given the effectiveness of this approach in these other areas, an approach informed by harm reduction principles could help improve self-management for some patients who experience numerous barriers in implementing traditional strategies for diabetes self-management. Additionally, we note that Baggett and colleagues report on their strategies for cardiovascular risk reduction in the context of homelessness, which employ similar principles to the harm reduction approach described here, highlighting that this strategy may have broad applications.40 The provision of specialized referrals to providers who are sensitive to the needs of people experiencing homelessness, described by participants in our study, has also been infrequently reported. This approach highlights the importance of inter-organizational collaboration and the development of partnerships and communities of practice.

One of the strengths of our qualitative study is that we included a large sample of multidisciplinary providers who represented a diverse range of programs. This allowed us to achieve robust saturation of themes. Using a qualitative study design, we were able to give providers the opportunity to speak openly, and at length, about the aspects of their programing that they felt were most effective or successful. As a result, we were able to collect rich information on approaches to care that are often less formal, and that may be challenging to evaluate quantitatively. However, given the nature of our data we are unable to draw any quantitative conclusions on the ability of these approaches to improve engagement or outcomes. Additionally, we did not interview people who had experience receiving service from these programs. Finally, our data collection was limited to Canadian centres, we did not include every urban centre in Canada, and we did not include smaller communities and rural areas, so our findings may not represent the strategies employed in all communities or health care systems.

In conclusion, we have demonstrated that there are common, broadly applicable approaches to providing high-quality diabetes care to those experiencing homelessness. In many cases, these are extensions of principles employed in providing comprehensive primary care for this population. By characterizing these approaches to care, we hope to offer a framework that can be used to better engage and serve this population across a variety of settings.

Hannah M. Yaphe, Rachel B. Campbell, Nicole L. Mancini, Eshleen K. Grewal, Tadios Tibebu, Terry Saunders-Smith, Stephen W. Hwang, and David J.T. Campbell

HANNAH M. YAPHE and NICOLE L. MANCINI are affiliated with the Department of Undergraduate Medical Education in the Cumming School of Medicine at the University of Calgary. RACHEL B. CAMPBELL, ESHLEEN K. GREWAL, and TERRY SAUNDERS-SMITH are affiliated with the Department of Medicine in the Cumming School of Medicine at the University of Calgary. TADIOS TIBEBU and STEPHEN W. HWANG are affiliated with the MAP Centre for Urban Health Solutions in the Li Ka Shing Knowledge Institute in the Unity Health Toronto at St. Michael's Hospital. DAVID J.T. CAMPBELL is affiliated with the Departments of Medicine, Community Health, and Cardiac Sciences in the Cumming School of Medicine at the University of Calgary.

Please address all correspondence to: David Campbell, University of Calgary, 3280 Hospital Dr. NW, TRW 3E33, Calgary, AB, Canada, T2N 1N4; Email: dcampbel@ucalgary.ca.

Data Availability

Deidentified interview transcripts are available upon request from the corresponding author.

Funding

Funding for this study was provided by grants from Alberta Innovates, O'Brien Institute for Public Health Vulnerable Populations Research Fund, and Cal Wenzel Family Cardiometabolic Research Fund. The study sponsor/funder was not involved in the design of the study; the collection, analysis, and interpretation of data; writing the report; and did not impose any restrictions regarding the publication of the report.

Conflict of Interest Statement

The authors do not have any conflicts of interest or relationships to declare.

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