Adapting your practice: treatment and recommendations for patients who are homeless with diabetes mellitus.

General

Guideline Title

Adapting your practice: treatment and recommendations for patients who are homeless with diabetes mellitus.

Bibliographic Source(s)

• Kalinowski A, Tinker T, Wismer B, Meinbresse M. Adapting your practice: treatment recommendations for patients who are homeless with diabetes mellitus. Nashville (TN): Health Care for the Homeless Clinicians’ Network; 2013 Jun. 24 p. [30 references]

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Brehove T, Joslyn M, Morrison S, Strehlow AJ, Wismer B. Adapting your practice: treatment and recommendations for homeless people with diabetes mellitus. Nashville (TN): Health Care for the Homeless Clinicians’ Network; 2007 Jun. 14 p.

Recommendations

Major Recommendations

Diagnosis and Evaluation

History

Current Symptoms

• Ask patients if they have had any symptoms of hypoglycemia or hyperglycemia. Ask questions regarding complications of diabetes (i.e., vision changes, paresthesias, skin changes/ulcers, chest pain).
• Ask patients how long they have known about their diabetes and if they have any known long-term complications (i.e., retinopathy, nephropathy, neuropathy, cardiovascular disease).

Current Health Behaviors and Treatment

• Ascertain patients’ current medications and how they are obtained.
• Assess patients’ recent adherence to previously recommended treatment advice (i.e., use of medication, missed doses, dietary changes, ability to exercise).
• Ask the patients about eating habits and patterns including nutrition status, weight history, and food sources (e.g., soup kitchens). Ask patients if they are able to follow an appropriate diabetic diet. Many food sources supply only one meal a day so that the homeless person must visit multiple places for food. Some shelters are able to provide alternatives to persons with special dietary needs.
• Determine if/where patients are getting medical help, advice, syringes, and test strips. Home glucose meters can often be obtained at no cost from companies as samples. In addition, many stores carry lancets and test strips at very affordable prices. These options should be researched and recommended as appropriate.
• Assess for medical and mental health comorbidities and associated medications.
• Explore the use of tobacco, alcohol and illicit drugs, and the frequency and route of use.

Past Medical History

• Ask patients if they have ever had foot sores or ulcers or any problems with their feet.
• Assess and often reassess how much walking patients are doing as well as the condition and fit of footwear.
• Obtain a sexual history including contraception and reproductive history.

Social History

• Assess where patients are living; e.g., shelter, on the street, doubled up. (“Doubled up” is a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/or extended family members.)
• Ask when patients last had permanent or regular place to live and if they ever had their own apartment or home.
• Ask patients if they have access to food and water when they want or need it (e.g., snacks).
• Assess patient understanding of diabetic illness and how to control it safely.
• Assess patients’ readiness to change behavior.
• Assess patients’ literacy level.

Physical Exam

• Obtain vital signs at each visit.
• Perform a full physical exam with particular focus on the cardiovascular, pulmonary, neurologic, and dermatologic systems.
• A comprehensive foot exam, including vibration and monofilament sensation, should be performed at least annually. A visual foot exam to evaluate for ulcers or other worrisome skin changes should be performed at each visit.
• Evaluate any insulin injection sites for signs of infection.

Diagnostic Tests

When available, it is important to review past lab results and their trends over time with patients.

• Perform dipstick urinalysis to test for ketones, glucose, protein and sediment, when indicated.
• The use of portable glycosylated hemoglobin (HbA1c) test kits is a valuable tool for point of care information. The results, available in fewer than ten minutes, can be used to enhance follow-up and patient education.
• To assess kidney status, the best test for homeless patients is the albumin- to-creatinine ratio (urine for microalbumin) in an early morning collection. If the test is elevated, repeat. Twenty four-hour urine testing is no longer recommended for screening and is not practical for many homeless patients.
• Evaluate patient lipid status. A fasting lipid profile provides more complete information, but patient low-density-lipoprotein (LDL) cholesterol can still be accurately measured if not fasting. Fasting may not be realistic or appropriate for some patients as food acquisition is a challenge for this population. Consider using direct LDL testing, which does not require patients to fast before having tests drawn. This is especially important for patients who often miss appointments.
• Consider testing for hepatitis B and C, human immunodeficiency virus (HIV), syphilis, and tuberculosis (TB), so as not to miss an opportunity for diagnosing and treating other conditions that may be more prevalent in this high-risk population.

Providers should also identify patients with prediabetes (impaired fasting glucose or impaired glucose tolerance) and attempt to intervene with lifestyle changes so as to prevent the development of diabetes. This can be diagnosed with an HbA1c test, which does not require fasting and may be easier to obtain.

Plan and Management

At each visit the clinician should:

• Review the diabetes treatment plan with the patient, including medication access and storage, glucometer use (if available), and warning signs of when to seek care sooner.
• Assess patient’s current living situation including where they live, how long they have lived there, who lives with them and their relationship to that person.
• Assess the psychological, sociological and economic factors that may affect the management plan. Refer the patient to community resources, as needed, e.g., Department of Social Services.
• Assess food sources.
• Obtain an emergency contact with a phone number.
• Obtain a phone number for the patient if possible. Some patients have cell phones, voice mail numbers or can receive messages at shelters or programs.

Tip : Patients receiving Supplemental Nutrition Assistance Program (SNAP) benefits or other public entitlements may exhaust their resources by the end of the month.

Glycemic Goals

In general, the goal for HbA1c is <7%. Some quality management programs have a target HbA1c of <8% to reduce the risk of hypoglycemia in particularly vulnerable patient populations. Before consideration of more stringent control in patients who are homeless, carefully review food access, regularity, control of diet, physical activity, and hypoglycemic events. Less stringent control may be indicated for some patients who are homeless, including those with ongoing hypoglycemic events, unstable living situation, inconsistent follow-up, ongoing substance use, poorly controlled mental illness, or significant cognitive impairment. A focus on more stable housing and stabilization of other health conditions may be needed first.

Patient Education and Self-Management

• Self-management goal-setting can be a useful method to involve patients in their health care. Allow patients to decide what is important for them in contributing to their health, even if goals are not directly related to a diagnosis of diabetes. This first step can provide patients with confidence to make further changes as needed.
• Providing culturally suitable education involving patients in the learning process is critical. Successful approaches to teaching persons experiencing homelessness include peer interaction and support groups.
• Assess patient basic literacy and health literacy and provide self-management education accordingly.
• Specifically ask patients about their understanding of diabetes and how to best control it. This will allow an opportunity to address possible misconceptions that would otherwise be unrecognized.
• Patients who are dependent on tobacco, alcohol or illicit drugs may not be ready or able to abstain from these substances. Helping the patient move in that direction may be the first goal. Many therapeutic interventions help decrease health risks until they are ready to change their behavior. Motivational interviewing, for example, is a successful technique to reduce risk of complications.
• For female patients planning pregnancy, it is important to discuss high risk pregnancy in regards to gestational diabetes and the need to connect with an obstetrician-gynecologist (OB/GYN) at the earliest opportunity for appropriate prenatal care.

Diet and Nutrition

Homeless persons are usually dependent on soup kitchens or shelters for meals, and it may be difficult to plan meals to coincide with insulin administration. Clinicians should work with shelters and soup kitchens to promote healthy food choices and to provide supplemental snacks to those with diabetes.

The clinician should:

• Assess where and when patients are eating, and the frequency and healthfulness of meals.
• Recognize that patients may choose to eat at local fast food restaurants and provide them with a list of healthier food choices available within these locations.
• Provide suitable documentation for the patient with diabetes to use at food pantries, soup kitchens and shelters to obtain healthful snacks and foods.
• Encourage patients to make the best choices that they can from what is available, for example, taking a smaller portion of macaroni and cheese and a larger portion of vegetables.
• Ask patients to save part of the meal for later when only one or two meals are available per day.
• Provide multivitamins with minerals.
• Acknowledge the patients’ limitations given food choices and work to adjust medications to address glucose control.

Tip : Tight glycemic control may be dangerous for patients on insulin or sulfonylureas who cannot reliably predict the number or timing of meals that they will eat that day.

Oral Health

Access to preventive dental services is often difficult for patients experiencing homelessness. The clinician can:

• Provide toothbrushes, toothpaste and dental floss.
• Teach basic oral health care, e.g., demonstrating proper brushing and flossing.
• Advise patients to rinse mouth with water after eating when brushing is not possible.
• Teach patients the importance of an annual oral examination even if they do not have teeth.
• Refer patients for an annual oral exam when possible.

Exercise

For people who are homeless, walking is their typical exercise and they usually carry their belongings, which increases the exercise effort. Patients with peripheral neuropathy or foot problems should take precautionary measures such as proper footwear. The clinician should:

• Remind patients that regular exercise is part of the diabetes treatment plan.
• Chart how far the client walks daily.
• When appropriate, suggest that the patient take steps instead of elevators.
• Assess the condition of the patient’s shoes and socks at every visit.
• Research possibilities for exercise monitors such as pedometers and options such as the Young Men’s Christian Association (YMCA) or other local fitness centers that can offer membership at reduced rates.

Foot Care

Foot problems often result from prolonged standing and walking. When combined with diabetes, the patient is at high-risk for foot ulcers. The clinician should:

• Encourage patients to keep feet dry and take shoes and socks off at night.
• Instruct patients to wash socks nightly, if possible, and dry thoroughly.
• Teach patients to inspect their feet daily.
• Teach patients how to examine their feet. If they cannot see the bottom of their feet, teach the patient how to use a mirror. Urge patients to visit the clinic immediately if they have open foot sores or areas of redness.
• Encourage patients to ask clinicians to check their feet each time they visit the clinic.
• Identify community resources for free shoes and socks, and refer patients as needed. Maintain a supply of clean socks to give to patients as needed. Provide padded socks when available.
• Consider having foot care products for patients, e.g., skin care lotions, corn cushions, mole skin, and lamb’s wool.
• Instruct patients to elevate legs to a level at or above their heart whenever possible to prevent/alleviate fluid stasis in lower extremities. This is especially important for patients who are sleeping in chairs.
• Refer patients to respite care if available for relief of diabetic foot conditions.
• Secure a podiatrist for referrals and consultation.

Self-Monitoring of Blood Glucose

Although self-monitoring of blood glucose is indicated when multiple insulin injections or an insulin pump are prescribed, and may be helpful with other therapies, patients who are homeless often have difficulty obtaining or managing glucometers or strips. If self-monitoring is not possible, the clinician should:

• Optimize control using non-insulin therapies or once daily insulin injections.
• Recommend frequent clinic visits to monitor blood glucose and complications.
• Instruct patients to recognize signs and symptoms of hypoglycemia and how to treat if present.

Insulin Therapy

Tight glycemic control can increase the risk of hypoglycemic episodes in homeless individuals due to a variety of physiological and adherence factors including excessive caloric expenditures, e.g., extensive walking; uncertain caloric intake, e.g., availability, content and timing of meals; and behavioral factors that may negatively affect adherence e.g., mental illness and substance abuse.

• Whenever possible, teach patients to adjust their own insulin dose based on food availability, blood sugar readings, and anticipated physical activity.
• Recommend decreasing insulin dosage when food is unavailable.
• Consider using basal insulin such as insulin glargine, if available, with insulin lispro, insulin aspart, or regular insulin before meals to accommodate irregular eating patterns.
• Use premixed insulin when needed to minimize complexity of the regimen.
• The use of insulin pens has proven convenient and successful, and may reduce the risk of theft for patients who might otherwise need to carry syringes. Providers should inquire in their area on how to access pens for patient use.
• If they are walking a great deal, encourage patients to inject insulin into the abdomen to avoid erratic absorption.

Insulin Storage

Since patients who are homeless usually have little or no access to refrigeration, consider these options:

• Assess whether patients can use a shelter’s refrigerator and whether the insulin will be accessible when needed.
• Store patients’ insulin at the clinic and dispense one vial at a time.
• Suggest storing insulin in an insulated bag.
• Provide insulated bags for insulin storage.
• Avoid pre-filling syringes and storing them in a communal refrigerator, e.g., in a shelter, where the medication integrity cannot be monitored safely.
• If refrigeration is unavailable, insulin can be safely stored at temperatures between 36 and 86 degrees Fahrenheit for up to one month. Therefore, recommend that patients avoid carrying insulin inside pants or shirt pockets. An alternative such as outer clothing or tote bag may be suggested.

Syringe Storage/Disposal

• Advise patients against reusing needles.
• Caution patients to store syringes securely since they can be stolen for illicit drug use.
• Advise patients that a pharmacy may provide one or two syringes if needed. Patient will need to show pharmacists their insulin supply.
• Instruct patients on proper syringe disposal emphasizing safety and offer options available in their area.

Non-insulin Therapy

People experiencing homelessness have high rates of chronic liver conditions and a high incidence of substance use with associated liver dysfunction. The clinician should:

• Assess liver function on a regular basis.
• Screen carefully for alcohol abuse before starting metformin.

For the patient taking sulfonylureas, the clinician should:

• Recommend that the patient hold or decrease the dosage when food is unavailable to avoid hypoglycemic episodes.

Dipeptidyl peptidase-4 (DPP-4) inhibitors could be useful in homeless patients because they do not cause hypoglycemia or weight gain but should be used with caution in patients with a history of alcohol abuse or high triglycerides ( >500) secondary to the risk of pancreatitis. Currently there is no generic available for these medications and patients without insurance may not be able to obtain these medications unless through medication bridge programs because of cost barriers.

• Depending which medications a patient is taking, a routine basic metabolic panel to evaluate electrolytes, serum creatinine, and liver function tests may be indicated to assess whether a patient can start or stay on a particular medication.

Non-insulin Injectables

Glucagon-like peptide-1 (GLP-1) receptor agonists come in injectable pen form, which requires refrigeration prior to opening. This may be difficult for persons experiencing homelessness who do not have access to refrigeration. The medications are low risk for causing hypoglycemia unless they are used in combination with sulfonylureas or insulin; they may be useful in patients who are obese because of the potential for weight loss. This class of medications should be used with caution in patients with a history of alcohol abuse or high triglycerides (>500) secondary to the risk of pancreatitis.

The long-lasting formulations of these medications only have to be injected once weekly, creating the potential for increased medication adherence.

Currently, there are no generics available for these medications, and patients without insurance may not be able to obtain these medications unless through medication bridge programs.

Hypoglycemia

Hypoglycemia has been associated with microvascular and macrovascular events and should be closely monitored especially with patients who are more at risk of hypoglycemic episodes. Assist patients to obtain a medic alert bracelet and a form of glucose that is easy to carry.

People who are homeless often do not have family members or friends available to help in an emergency. Clinicians should teach shelter and program (e.g., residential treatment, supportive housing) staff the signs and symptoms of hypoglycemia. This is critical since hypoglycemia may be mistaken for intoxication or a behavioral health issue as some individuals can become aggressive. If the patient is conscious and able to swallow, the staff can give oral glucose, e.g., an orange drink. If the patient is unresponsive or unable to swallow, the staff should immediately call 911 for help.

Work with shelter and program staff to provide diabetic appropriate snacks for patients.

If available, family members or friends should be taught to recognize the signs and symptoms of hypoglycemia; how to administer oral glucose or an injection of glucagon, if prescribed, should the patient be unresponsive or unable to swallow; and to call 911 when indicated.

Management of Associated Problems and Complications

Patients who are homeless have been shown to more often have an external locus of control leading to a feeling of whatever happens to them is out of their control. This can make a disease such as diabetes, which requires patient participation in management, difficult to control, increasing morbidity and mortality related to the disease. This section reviews the macrovascular and microvascular complications of diabetes and provides suggestions on how to identify and minimize risk.

Cardiovascular Disease

Cardiovascular disease is the primary cause of death for persons with diabetes. The plan for decreasing complications should target blood pressure and lipids, primarily focusing on low-density lipoprotein cholesterol (LDL-C) reduction in addition to glycemic control.

• Smoking cessation is an important component of education on diabetes complications.

Hypertension

The DASH (Dietary Approaches to Stop Hypertension) diet is recommended for persons with diabetes and hypertension. Persons who are homeless may have difficulty accessing foods which are not high in sodium.

The first line of therapy is an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) and multiple drug therapy is generally required. When considering using a diuretic for blood pressure control, the clinician should:

• Assess patient access to bathroom facilities.
• Assess patient access to water and other fluids if the patient is living outside in a hot climate.

Lipid Management

Statin therapy is recommended in patients with cardiovascular disease or those without cardiovascular disease but who are over the age of 40 with one or more other cardiovascular disease risk factors. These risk factors are family history of cardiovascular disease, hypertension, smoking, dyslipidemia or albuminuria.

If a patient is using statins for hyperlipidemia and abusing alcohol and other drugs, consider screening liver function more frequently.

Aspirin

Aspirin is recommended for patients at high cardiovascular risk, however it is no longer recommended for those at low risk. The benefit from aspirin must always be balanced with the risk of bleeding.

Diabetic Nephropathy

Blood pressure and blood sugar control are important to lowering the risk of nephropathy. In patients who already have albuminuria, the restriction of protein helps slow its progression and decreases the occurrence of end stage renal disease. Access to specific renal or low sodium diets may be difficult for homeless persons.

Diabetic Retinopathy

Retinopathy and uncontrolled high blood pressure are closely linked; lowering blood pressure not only lowers the risk of retinopathy it also decreases the progression of retinopathy. However, extremely low blood pressure can also have negative health effects. It is recommended to maintain systolic pressure of 140 and diastolic pressure of 80.

• Access to eye exams may be difficult for patients who are homeless due to a lack of insurance. Consider partnering with local ophthalmologists and optometrists to obtain free exams.
• Refer patients for diabetic retinopathy screening annually. Some facilities have access to digital retinal cameras and can be evaluated by an ophthalmologist remotely.

Neuropathy

Risk for neuropathic complications is most closely related to glycemic control.

• Neuropathy can also be caused by alcohol abuse and may not be related to diabetes.

Diabetic Foot Ulcers

The risk for ulcers and amputations is increased in persons who are homeless secondary to a higher prevalence of risk factors such as poor glycemic control and cigarette smoking.

Diabetic foot ulcers can be slow-healing wounds that respond well to basic clean wound care and off-loading of weight. Off-loading of weight can be achieved either through obtaining convalescent care (bed rest) or, if available, outpatient, specialty medical care (podiatric or orthopedic), which can provide boots or casting. It is rare that ulcers alone can qualify for hospital-level care although medical respite or medical rehabilitation facilities can be utilized where available.

Sufficient bed rest may not be possible for the homeless person since many shelters are not open during the day. Clinicians should work with shelter staff and other homeless service providers to ensure that convalescent care is available. Convalescent care may include access to a motel room or 24-hour shelter beds for those needing bed rest.

However, diabetic foot ulcers may also lead to serious and rapidly progressive infections requiring hospital level care. Because of the difficulty of monitoring infections in the homeless context, as well as the short amount of time in which infection can progress in the diabetic patient, referral to a higher level of care should be considered and attempted early.

When referring patients for hospital level care, it may be helpful to emphasize not only key clinical data but also assist the evaluating hospital clinicians to appreciate the context and confounders to what might otherwise be appropriate out-patient care.

• Presence of redness and warmth around the wound, especially if the patient is already getting good daily wound care or taking an antibiotic (if the wound is not progressing after one day, advanced care may be needed).
• Fever (temperature >100.5 degrees Fahrenheit)
• Diagnosis of diabetes and a recent blood glucose level; also, a general statement about the patient’s usual control (e.g., “poorly controlled”), and the need for insulin (“insulin dependent”) for daily management.
• Context of homelessness is an important consideration in judging the success of out-patient monitoring and patient ability to self-care and self-refer upon worsening.
• Ongoing substance abuse is very high risk for poor attention to progression of infection and ability to self-refer for care upon worsening.
• Some symptoms of mental illness (e.g., paranoia, apathy, delusion) also can be barriers to self-care and ability to self-refer upon worsening.
• Offering post-hospital care and follow-up can help alleviate non-clinical barriers to homeless patients being admitted to hospital level care.

Gastrointestinal Neuropathy

Many sections of the gastrointestinal tract can be affected, leading to problems such as gastroparesis which can make glucose control erratic.

• Clients may experience constipation alternating with diarrhea. Shelter staff may need to be informed so that patients can have access to bathroom facilities.

Erectile Dysfunction

Erectile dysfunction has been reported in as many as 46% of men with type 2 diabetes. Erectile dysfunction has been shown to be an early marker of cardiovascular disease and shares the same risk factors, such as smoking, obesity, and dyslipidemia. The clinician should:

• Assess all male patients with diabetes for erectile dysfunction, as well as comorbidities such as smoking and depression.
• When treating hypertension, consider the use of ACEs and ARBs, which may have a beneficial or neutral effect versus other classes of hypertension medications, which can contribute to erectile dysfunction.
• The degree of erectile function is inversely related to HbA1c; as HbA1c rises, erectile function declines; teach male clients the importance of glycemic control.
• Testosterone deficiency is also seen in the male with erectile dysfunction; consider testosterone replacement therapy in the presence of symptoms of deficiency and a low testosterone level.
• Cigarette smoking increases the risk of erectile dysfunction; smoking cessation has been shown to decrease the risk of erectile dysfunction.

Diabetic Ketoacidosis and Nonketotic Hyperosmolar State

Diabetic ketoacidosis is a life-threatening condition which requires immediate medical care. Patients who are homeless may lack access to insulin or lack transportation to obtain insulin, which puts them at high risk for hyperglycemic crisis. Recurrent diabetic ketoacidosis is more likely in patients who are homeless, have a history of homelessness or incarceration, or are using drugs or alcohol.

• Diabetes medications, sick day management, and when to seek care should be reviewed with all patients admitted to the hospital with diabetic ketoacidosis.
• The majority of diabetic ketoacidosis admissions could be prevented by improved access to care, diabetes education, and effective communication with a clinician during an illness.

Comorbid Conditions

Oral Health

Poor oral hygiene is common among people experiencing homelessness. Dental abscesses and periodontal disease contribute to poor glycemic control. The clinician should identify free or discounted dental services available within the community. Dental schools, public health departments and private dentists who volunteer their services can be valuable resources.

Substance Use

The patient who is not ready or able to abstain from alcohol or drug use is at higher risk of hospitalization for diabetes complications.

• Stress the importance of eating. Assess the patient’s diet and ability to eat consistent meals at consistent times, especially if the patient is taking medications which can cause hypoglycemia (insulin, sulfonylureas).
• If the patient is drinking alcohol, assess amount. Teach the patient caloric content of alcohol and effect on glucose management. Review risk of hypoglycemia, signs and symptoms of hypoglycemia, and how to treat it.
• Encourage the patient to seek shelter on nights when weather is extreme, e.g., cold, hot, or wet.
• Consider using motivational interviewing techniques and risk reduction methods to guide the patient toward abstinence.
• Suggest more frequent office visits to encourage goal setting and closely monitor the diabetes progression.

Nicotine Dependence

Almost 60% of patients served by the Health Care for the Homeless program report being current smokers. For the patient who is dependent on nicotine, the clinician should refer or enroll the patient in a smoking cessation program. Smoking causes vasoconstriction that increases the risk of frostbite. For patients living outside or in poorly heated places, the clinician should:

• Explain the relationship between smoking, vasoconstriction and diabetes.
• Recommend that the patient always wear gloves and carry an extra pair of socks to change into when feet get damp.

Smoking increases risk of pulmonary infection and may contribute to a vitamin C deficiency that can affect wound healing. The clinician should:

• Stress hand washing to decrease the transmission of organisms.
• Provide annual influenza vaccines and encourage the administration of the pneumococcal vaccine.
• Teach the patient about good food sources of vitamin C.
• Consider providing vitamin supplements.

Smoking is considered a major risk factor for macrovascular complications, such as cardiovascular disease, and microvascular complications, such as nephropathy, retinopathy, and neuropathy. The clinician should:

• Explain the increase in risk of cardiovascular morbidity and mortality.
• Review the link between smoking and development of diabetes complications.

Mental Illness/Impairment

Approximately 70% of individuals who are homeless and served by the Health Care for the Homeless program have experienced psychological distress and 25% percent of sheltered individuals who are homeless have a severe mental illness. Patients with mental health conditions have a higher prevalence of diabetes but fewer recommended laboratory tests for diabetes monitoring and screenings for complications. These patients are at higher risk of hospitalization for diabetes complications and experience not only a higher diabetes mortality rate but also a higher all-cause mortality rate. Also, patients with severe depression may be less likely to adhere to medication and dietary treatment regimens.

In addition, patients who are homeless may have developmental delays and impaired cognitive functioning. These patients may experience the following:

• Impaired thinking processes that result in disorientation and a disorganized lifestyle
• Lack of motivation to seek help
• Lack of insight or understanding of their illness, which may result in denial of the need for services
• Negative experiences with mental health institutions
• Unpleasant medication side effects
• A decreased likelihood of HbA1c testing

Patients prescribed atypical antipsychotic medications are at increased risk for the development of obesity, hyperlipidemia, and hyperglycemia. For these patients, providers should carefully monitor weight, lipids, and glucose, and consider typical or atypical antipsychotics which are less likely to cause weight gain.

For providers not in Health Care for the Homeless projects that offer mental health services, connecting with other agencies that offer counseling and therapy will help greatly in managing the plan for the homeless patient with a mental impairment.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Diabetes mellitus

Other Disease/Condition(s) Addressed

• Dental abscess
• Dyslipidemia
• Erectile dysfunction
• Gastrointestinal neuropathy
• Hypertension
• Mental illness
• Periodontal disease
• Substance-related disorders
• Tobacco dependence

Guideline Category

• Counseling
• Diagnosis
• Evaluation
• Management
• Treatment

Clinical Specialty

• Cardiology
• Emergency Medicine
• Endocrinology
• Family Practice
• Internal Medicine
• Nephrology
• Neurology
• Nutrition
• Ophthalmology
• Podiatry

Intended Users

• Advanced Practice Nurses
• Allied Health Personnel
• Dentists
• Dietitians
• Health Care Providers
• Nurses
• Pharmacists
• Physician Assistants
• Physicians
• Podiatrists
• Public Health Departments
• Social Workers
• Students
• Substance Use Disorders Treatment Providers

Guideline Objective(s)

To recommend adaptations in standard clinical practices to improve quality of care and health outcomes for homeless adults with diabetes mellitus

Target Population

Homeless adults with diabetes mellitus

Interventions and Practices Considered

Diagnosis/Evaluation

1. History, including current symptoms of hypoglycemia or hyperglycemia, current health behaviors and treatment, past medical history, and social history
2. Physical examination, including vital signs, full physical examination, comprehensive foot exam
3. Diagnostic tests, including dipstick urinalysis, portable glycosylated hemoglobin (HbA1c) test, albumin-to-creatinine ratio, lipid profile, testing for hepatitis B and C, human immunodeficiency virus (HIV), and tuberculosis

Management/Treatment

1. Review of diabetes treatment plan and patient’s current living situation
2. Setting glycemic goals
3. Patient education and self-management goal-setting
4. Ensuring appropriate diet and nutrition: working with shelters and soup kitchens to promote healthy food choices
5. Management of oral health
6. Ensuring appropriate exercise
7. Ensuring adequate foot care with regular foot examinations
8. Self-monitoring of blood glucose
9. Insulin therapy
10. Ensuring adequate insulin storage and syringe storage/disposal
11. Choice of non-insulin therapy (sulfonylureas, dipeptidyl peptidase-4 [DDP-4] inhibitors, glucagon-like peptide-1 [GLP-1] receptor agonists)
12. Monitoring hypoglycemia
13. Management of associated problems and complications, including cardiovascular disease (hypertension and lipid management, aspirin therapy), diabetic nephropathy, diabetic retinopathy, neuropathy (diabetic foot ulcers, gastrointestinal neuropathy, erectile dysfunction), diabetic ketoacidosis and nonketotic hyperosmolar state, poor oral health, substance use, nicotine dependence, and mental illness/impairment

Major Outcomes Considered

• Risk of hypoglycemia
• Risk of diabetes complications
• Adverse effects of medications

Methodology

Methods Used to Collect/Select the Evidence

• Hand-searches of Published Literature (Primary Sources)
• Hand-searches of Published Literature (Secondary Sources)
• Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

A literature search was conducted on PubMed using the terms “homeless” and “diabetes” to identify the most up-to-date research on diabetes care for homeless and other vulnerable populations. References were also identified through online searches of current diabetes guidelines and bibliographies of relevant reports. The time frame for the literature searches was approximately May 2007 to May 2013.

References cited and included in the guidelines were ultimately selected by the advisory committee. Selection (inclusion/exclusion criteria) was based on the judgment of these experienced homeless services providers regarding the validity, significance, and usefulness of the publications to clinicians whose patients include individuals who are homeless or at risk of homelessness.

Number of Source Documents

This guideline is adapted from one primary source.

Methods Used to Assess the Quality and Strength of the Evidence

• Not stated

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

• Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

• Expert Consensus

Description of Methods Used to Formulate the Recommendations

In 2002, the Health Care for the Homeless Clinicians’ Network developed adapted clinical guidelines for the care of adults experiencing homelessness with diabetes. The guidelines were updated once in 2007 and are now being updated once again. The American Diabetes Association’s Standards of Medical Care in Diabetes —2013 is the source document for these current adaptations (American Diabetes Association [ADA], 2013). Recommendations found in the ADA diabetes guidelines are not restated in this document except to specify a particular adaptation.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

• External Peer Review

Description of Method of Guideline Validation

The guideline developer’s Advisory Committee identifies, in the original guideline document, the clinicians who reviewed and commented on the draft recommendations prior to publication.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

This is a guideline adapted from the American Diabetes Association’s Standards of Medical Care in Diabetes —2013 (see the “Adaptation” field for full citation).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate quality of care for homeless patients with diabetes mellitus in order to improve treatment adherence and patient outcomes

Potential Harms

• Tight glycemic control can increase the risk of hypoglycemic episodes in homeless individuals due to a variety of physiological and adherence factors including excessive caloric expenditures, e.g., extensive walking; uncertain caloric intake, e.g., availability, content and timing of meals; and behavioral factors that may negatively affect adherence e.g., mental illness and substance abuse.
• Hypoglycemia has been associated with microvascular and macrovascular events and should be closely monitored.
• Dipeptidyl peptidase-4 (DPP-4) inhibitors could be useful in homeless patients because they do not cause hypoglycemia or weight gain but should be used with caution in patients with a history of alcohol abuse or high triglycerides (>500) secondary to the risk of pancreatitis.
• Glucagon-like peptide-1 (GLP-1) receptor agonists are low risk for causing hypoglycemia unless they are used in combination with sulfonylureas or insulin. This class of medications should be used with caution in patients with a history of alcohol abuse or high
• Patients prescribed atypical antipsychotic medications are at increased risk for the development of obesity, hyperlipidemia, and hyperglycemia. For these patients, providers should carefully monitor weight, lipids, and glucose, and consider typical or atypical antipsychotics which are less likely to cause weight gain.
• The benefit from aspirin must always be balanced with the risk of bleeding.

Qualifying Statements

Qualifying Statements

• The contents of this guideline are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources & Services Administration.
• Recommendations found in the American Diabetes Association (ADA) diabetes guidelines are not restated in this document except to specify a particular adaptation. Hopefully, these simple adaptations of established diabetes guidelines can help improve treatment adherence and health outcomes for patients experiencing homelessness.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

• Resources

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

• Living with Illness
• Staying Healthy

IOM Domain

• Effectiveness
• Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

• Kalinowski A, Tinker T, Wismer B, Meinbresse M. Adapting your practice: treatment recommendations for patients who are homeless with diabetes mellitus. Nashville (TN): Health Care for the Homeless Clinicians’ Network; 2013 Jun. 24 p. [30 references]

Adaptation

The guideline was adapted from: American Diabetes Association. (2013). Standards of Medical Care in Diabetes—2013. Diabetes Care , 36: S11-S66.

Date Released

2002 Jun (revised 2013 Jun)

Guideline Developer(s)

• Health Care for the Homeless (HCH) Clinician’s Network - Medical Specialty Society
• National Health Care for the Homeless Council, Inc. - Nonprofit Organization

Source(s) of Funding

This publication was made possible by grant number U30CS09746 from the Health Resources & Services Administration, Bureau of Primary Health Care.

Guideline Committee

Advisory Committee on Adapting Clinical Guidelines for Homeless Individuals with Diabetes Mellitus

Composition of Group That Authored the Guideline

Committee Members : Aaron Kalinowski, MD, MPH, Eskenazi Medical Group at Horizon House, Assistant Professor of Family Medicine and Clinical Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Tracy Tinker, RN, MSN, CDE, Healthcare for the Homeless, Catholic Medical Center, Manchester, NH; Barbara Wismer, MD, MPH, Tom Waddell Health Center, San Francisco Department of Public Health, San Francisco, California; Molly Meinbresse, MPH ( Editor ), National Health Care for the Homeless Council, Nashville, TN

Financial Disclosures/Conflicts of Interest

The Heath Care for the Homeless (HCH) Clinicians’ Network has a stated policy concerning conflict of interest. First, that all transactions will be conducted in a manner to avoid any conflict of interest. Secondly, should situations arise where a member is involved in activities, practices or other acts which conflict with the interests of the Network and its Membership, the member is required to disclose such conflicts of interest, and excuse him or herself from particular decisions where such conflicts of interest exist.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Brehove T, Joslyn M, Morrison S, Strehlow AJ, Wismer B. Adapting your practice: treatment and recommendations for homeless people with diabetes mellitus. Nashville (TN): Health Care for the Homeless Clinicians’ Network; 2007 Jun. 14 p.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the National Health Care for the Homeless Council, Inc. Web site.

Print copies: Available from the National Health Care for the Homeless Council, Inc., P.O. Box 60427, Nashville, TN 37206-0427; Phone: (615) 226-2292

Availability of Companion Documents

The National Health Care for the Homeless Council has developed a variety of resources to support health care providers in their service to persons experiencing homelessness. These resources are available for purchase as well as free of charge from the National Health Care for the Homeless Council, Inc., Web site.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on May 24, 2004. The information was verified by the guideline developer on June 24, 2004. This NGC summary was updated by ECRI Institute on June 29, 2007. The information was verified by the guideline developer on July 13, 2007. This NGC summary was updated by ECRI Institute on April 22, 2014. This summary was updated by ECRI Institute on April 3, 2015 following the U.S. Food and Drug Administration advisory on Testosterone Products. This summary was updated by ECRI Institute on September 15, 2015 following the U.S. Food and Drug Administration (FDA) advisory on DPP-4 Inhibitors for Type 2 Diabetes. This summary was updated by ECRI Institute on April 12, 2016 following the U.S. Food and Drug Administration (FDA) advisory on Diabetes Medications Containing Saxagliptin and Alogliptin. This summary was updated by ECRI Institute on April 15, 2016 following the U.S. Food and Drug Administration advisory on Metformin-containing Drugs. This summary was updated by ECRI Institute on November 17, 2016 following the U.S. Food and Drug Administration advisory on Testosterone and Other Anabolic Androgenic Steroids (AAS).

Copyright Statement

All material in this document is in the public domain and may be used and reprinted without special permission. Citation as to source, however, is appreciated. Suggested citation: Kalinowski, A., Tinker, T., Wismer, B, and Meinbresse, M. (2013). Adapting Your Practice: Treatment and Recommendations for People Who Are Homeless with Diabetes Mellitus. Nashville: Health Care for the Homeless Clinicians’ Network.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.