Diabetes - Boston Health Care for the Homeless

DiabetesGregory A. Wagoner, MD, MBADiabetes mellitus is commonplace and touches the lives of most Americans,either directly or by affecting friends, family members, or colleagues. About18 million people are reported to suffer from diabetes in the USA, about6.3% of the entire population. Over one-third (40%) of Americans with diabetesare over the age of 65. And diabetes is on the rise in the USA. From 1980 to 1996the prevalence of diabetes rose 18.4%, while in the brief period between 1997 and2000 this rate increased another 12%.Diabetes is more common in black and Hispanicpeople than in white people. Among those youngerthan 75 years of age, African-American women hadthe highest prevalence. In other poor populations,the percentages are higher than the general population.Most observers and clinicians fear that theprevalence of this chronic and debilitating disease isreaching epidemic proportions among many vulnerablepopulations.Persons with diabetes can develop manycomplications as a result of damage to organs, suchas the kidneys, eyes, heart, blood vessels, and skin.Treatment of the disease and prevention of thesecomplications require a significant commitment onthe part of both the patient and the care provider.For many people, life-style changes may alleviate theneed for medication in the early stages of the disease.These changes primarily involve diet and exercise,neither of which is easy to control for persons whosleep in shelters and eat in soup kitchens. Walking isoften the only practical exercise, as exercise facilitiesare not generally accessible to homeless people.Jane L is a 48 year old diabetic diagnosed sixmonths previously at the local homeless clinic aftercomplaining of fatigue and frequent urination. Shereported that her mother had diabetes and died of astroke at age 55. Her primary care clinician has givenher abundant written information about her disease,but Jane does not comprehend the complications of herillness and is confused about how the treatment works.The fatigue and the frequent urination continueunabated, and Jane now feels depressed and anxiousabout her new diagnosis of diabetes.Jane lives at a shelter for women, eats daytimemeals at a nearby women’s center or downtown soupkitchen, and walks about 4 miles each day as shecompletes her daily routine. Wary of medication, sheA diabetic patientsimplifies the processof injecting insulin byusing an automaticinjection device, an“insulin pen”.Photo byJessie McCary MDThe Health Care of Homeless Persons - Part IV - Diabetes 253

manages to take pills for blood pressure and thyroidproblems. She has been told that she will need to starta new pill for her diabetes but may require insulin viaa needle if her blood sugars do not respond to the pillsor her changes in diet and activity. Despite good intentions,she has little control of her diet and must acceptthe meals offered. With the pressure of finding a bed forthe night and the next meal, finding the time and placeto exercise is virtually impossible.Her blood sugar and glycosylated hemoglobin(hemoglobin A1C) tests remain high, and after amonth her doctor prescribes two injections of insulindaily. Jane has no insurance and is unable to fill theprescription for insulin, syringes, and needles for severalweeks. She needs education and training in the useand administration of insulin, a place to refrigerate hermedication as well as a safe place to keep her needles,and assistance with monitoring her progress once shebegins the injections. All of these present complexbarriers that need to be overcome during her dailysearch for housing, food, and safety.Suffice it to say, she will need to make the care andtreatment of her diabetes an integral part of her dailyneeds – a day already filled with so many survival issuesthat such a burden is extremely difficult to bear. Shecontinues to see her primary care clinician regularly butbecomes depressed by the number of appointments sheneeds to remember, including the eye doctor, the nutritionist,the podiatrist, and the dentist. Sometimes, inthe midst of her poverty and homelessness, it simplydoesn’t feel worth the effort. She believes that she willprobably “get by” as long as she just keeps doing whatshe did before. Her sugars improve a little, but thefatigue and her depression are overwhelming and shejust wants to sleep.This story is not unusual and typifies the challengesfaced by homeless persons who have beendiagnosed with diabetes. Coordination of care andadherence to the treatment plan can be daunting toboth patient and provider. The necessary educationand support often require more time and resourcesthan are available, and important components of theprevention and treatment of diabetes are deferred orforgotten in our current clinical settings.The alternative is evidence-based decisionmakingand a supportive system of care in whichdecisions are made by both patient and provider.Jane needs a health care delivery system that emphasizescollaborative, team-based care that will supportthe major behavioral changes necessary to controlthe diabetes and reduce the risk of devastatingcomplications.Solid clinical evidence provides the basis ofcurrent treatment guidelines for diabetes, whichshould be an integral component of the care thateach homeless person receives. The majority of thedata come from a few key studies that are availablein the literature. These guidelines help eliminate“doing the wrong things” and emphasize activitiesthat yield the greatest rewards in the form of qualityof life and risk prevention. By adopting the CareModel, practitioners have a heightened chance ofeliminating the gap between what we know andwhat we do.The Care Model, as used and developedthrough the Bureau of Primary Health Care’sHealth Disparities Collaboratives, incorporateskey measurements and activities that have beenshown in the literature to be clearly beneficial forpopulations with diabetes. Several key studies formthe majority of this evidence. The HOPE studydemonstrated the benefit of the use of ACE-inhibitorsfor persons with diabetes over the age of 55. Inanother study sponsored by the Medical ResearchCouncil and the British Heart Association, the useof statins resulted in 33% reduction in heart attacksand strokes. The benefits of blood pressure controlwere studied in a large clinical trial called the UKProspective Diabetes Study. A total of 1148 patientswith diabetes showed dramatic reductions in strokes,microvascular complications, and diabetes-relateddeaths. Every reduction of 1% in the HgbA1Cresulted in reductions of 17% in mortality, 18% inmyocardial infarctions, 15% in strokes, and a 35%in cardiovascular endpoints.Lowering blood glucose has been definitivelyshown to slow the onset of complications ofdiabetes in one of the largest and most comprehensivestudies to date. The Diabetes Control andComplications Trial (DCCT), conducted by theNational Institute of Diabetes and Digestive andKidney Diseases, compared standard and intensivetherapy of type 1 diabetes through glucose controlmeasurements. The findings were dramatic. Eyedisease was reduced by 76%, neurological pathologywas reduced by 60%, and kidney disease was cut inhalf.Based on a list of key measurements on diabetesfurnished by the Health Disparities Collaborative ondiabetes, the Boston Health Care for the HomelessProgram chose several indicators to be followed on amonthly basis among the diabetic patients includedin the collaborative:• two HgbA1C’s annually (at least 3 monthsapart);254 The Health Care of Homeless Persons - Part IV - Diabetes

• blood pressure control (under 130/80);• annual dental exam;• documented self-management goals;• ACE inhibitors used in patients over 55years of age;• HgbA1C under 7.0%;• population of focus size.Components of CareAs discussed in a previous chapter, the CareModel has six components of care, which areexplained in detail. The remainder of this chapterwill use one example from each component to illustratecurrent testing or complete implementationof change within the diabetic collaborative patientpopulation.Health Care OrganizationThe organization has begun integrating theCare Model into the business plan in several ways.The spread of this effort through additional parts ofthe organization is part of the Annual Plan for theupcoming year. Participation in the model of care isa part of performance evaluations for all clinicians.The Board receives regular informational updates,including monthly reports.Clinical Information SystemsThrough the use of the software and registrysystem provided by the Health Disparities Collaborative,reports are now generated for the diabeticpopulation of focus that indicate areas where furtheractions are likely indicated. For instance, we cangenerate a report of all those diabetics in our populationwho have not had dental exams in the past year.This report can then be used to generate remindersor inform the clinician so that these services will bescheduled at the next visit.Decision SupportThe organization now has deployed portableHbgA1C devices at selected sites. These devicesprovide a way to measure this number accuratelyand have results within minutes, so that feedbackto the patient occurs during the same visit. Thedevices also need no electric supply, and are usefulon the street or in other locations without power.Delivery System DesignA team has been created which is multidisciplinaryand allows for better coordination ofaccess for our diabetic patients and more completeexchange of information. Other areas of changehave included the use of an eye specialist referralform which patients take to the eye doctor and thenreturn with the necessary information. This formhas improved greatly our ability to obtain feedbackfrom specialty visits.Community ResourcesUsing qualified volunteers, diabetes educationclasses have been instituted at our 92-bed respite carefacility and one large shelter in our system. Theseclasses have allowed for more detailed and individualizedinformation exchange in a place where accessfor our patients is easy and the setting familiar.These classes have been extremely successful, bothas measured by participant enthusiasm and overallattendance.Self-Management SupportAn easy-to-use handout has been used to workwith diabetic clients to choose a self-managementgoal that they want to work on. Clinicians in thecollaborative have established standardized ways todocument and follow these goals in the electronicmedical record.SummaryThe delivery of care based on the Care Modelhas been shown to be effective and realistic. TheBoston Health Care for the Homeless Program candocument wonderful examples that serve as proofthat this model of care works. Although we haveonly been involved in this initiative for less thana year at the time of this writing, staff membersinvolved in this initial phase have enthusiasticallysupported its use and endorsed its spread to all areasof the organization. Comparison of the care deliveredthrough this approach versus the traditionalmodel reveals gaps that must be eliminated in orderto assure high quality care for all of our diabeticThe patient dials inthe desired numberof units of insulininstead of manuallyfilling a syringe.Photo byJessie McCary MDThe Health Care of Homeless Persons - Part IV - Diabetes 255

clients. Diabetes management is difficult evenunder the best of situations, and for the homelessdiabetic, broad support and access to appropriateservices is extremely difficult. This model of careresults in an evidence-based prioritization of actionsby both the patient and the clinician. Care movesfrom an approach characterized by more episodic,reactive visits with little patient involvement toa model that includes the patient and results inimprovements that will hopefully reduce morbidityand mortality in the future. EReferencesAmerican Diabetes Association. Insulin administration. Diabetes Care 2002;25:S112-115.Brehove T, Bloominger MJ, Gillis L, et al. Adapting Your Practice: Treatment and Recommendations for Homeless Peoplewith Diabetes Mellitus. Nashville: Health Care for the Homeless Clinicians’ Network; 2002.Ridolfo AJ, Proffitt BJ. Diabetes and Homeless: Overcoming Barriers to Care. Nashville: Health Care for the HomelessClinicians’ Network; 2002.Uphold CR, Graham MV. Diabetes Mellitus: Clinical Guidelines in Family Practice. Gainesville, Fla.: Barmarrae Books;2002:140-155.Web sites:American Diabetes Association www.diabetes.orgHealth Disparities Collaboratives www.healthdisparities.netNational Guidelines Clearinghouse www.guideline.gov256 The Health Care of Homeless Persons - Part IV - Diabetes