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A community outreach service for vulnerable people with diabetes

David Gable
, Janet Ridout
, Julie Man
, Silvia Hepburn
, Martin Jones

Specialist diabetes care in the community is not always flexible enough to accommodate vulnerable people with complex needs. This article outlines the development of a specialist outreach service designed to meet the needs of local people with diabetes who are homeless, housebound, in residential or nursing care, or who have severe mental health problems. Each person identified as vulnerable is allocated to a case manager whose role is to facilitate their access to specialist diabetes care through liaison with other local services, outreach visits and discussion with the multidisciplinary team at virtual clinics. To illustrate the pathway in action, three different examples are given of how the team has worked to give sensitive and flexible individualised care to people who might otherwise have “fallen out” of the system.

The Westminster Diabetes Centre, provided by Central London Community Healthcare NHS Trust, provides intermediate level diabetes care in the community. The multidisciplinary team (MDT) consists of consultants, nurses, dietitians, podiatrists and a clinical psychologist, who are all diabetes specialists. The MDT aims to ensure that all Westminster patients, not only those who attend clinics, have equal access to specialist diabetes care. The team created a dedicated outreach service for people with complex needs, especially homeless or housebound people, those in nursing homes or who have severe mental health problems. The team has developed skills and expertise in supporting these “hard-to-reach” people, providing person-centred diabetes care that is integrated with other local services. This article describes the approach and gives three case examples (Boxes 1–3).

The problem of equality of access
Conventional diabetes services require patients to keep track of appointments, attend clinics when invited, and behave appropriately once there. If they fail to do this, they may be discharged due to pressure to see other patients who attend well. However, there may be valid reasons why some people fail to attend clinics. Many are too unwell to leave their homes or nursing beds. Others are homeless or have severe mental health problems.

Equality of access should be a priority for all NHS services (Department of Health [DH], Policy and Strategy Directorate, 2008) and vulnerable people with complex needs should not be excluded from specialist care simply because they fail to fit traditional clinics. This team identified four “hard-to-reach” groups within the local Westminster population who might fail to access healthcare through conventional clinics: the homeless (rough sleepers and those in hostels), those in community psychiatric care (such as community mental health teams), people with severe mental health problems, and those who are housebound or in residential or nursing care.

While the rationale for non-attendance at normal clinics may be more obvious for those who are too unwell to leave their beds than for those who are homeless or have mental health problems, the problem of access may be just as large, and the consequences as severe, for these groups. If diabetes services are inflexible in their approach, it follows that people who cannot attend clinics will not be able to access specialist care. Healthcare services have a duty to try to provide care closer to people’s homes (DH, 2008) and outreach provides one solution to this problem.

Mental illness significantly worsens diabetes outcomes. Symptoms of severe mental health problems (such as schizophrenia or bipolar depression) can cause people to live chaotic and restricted lives and impair their ability to take in educational information, reducing adherence to diabetes treatments (Ciechanowski et al, 2000). Furthermore, some psychotropic medications are associated with an increased risk of diabetes (Koro et al, 2002). Diabetes is prevalent in about 20% of people diagnosed with a severe mental illness and these people tend to die an average of 10–15 years earlier than others with diabetes (Healthcare for London, 2009). Mental health problems are highly prevalent in those without permanent housing, with up to 50% of homeless people suffering significant mental health problems and around 10% abusing substances (Scott, 1993; Hayward, 2007).

Diabetes rates are also elevated among the homeless (Healthcare for London, 2009). In Westminster, as many as 3000 “hidden homeless” people live in temporary accommodation, along with about 150 rough sleepers. Homeless people also have chaotic and transient lifestyles and face adversity which makes clinic attendance difficult. As a result, one study found that 44% of homeless people with diabetes had poor glycaemic control (HbA1c level >7% [>53 mmol/mol]; Hwang and Bugeja, 2000).

The outreach team in Westminster developed a pathway to better accommodate people with complex needs. All referrals sent to the general clinic are triaged and people with complex needs are then diverted to outreach. Referrals are also made internally for people who were not initially identified as vulnerable, but have failed to attend clinics due to vulnerability. At the weekly outreach meeting, all referrals are triaged and each patient is allocated to a member of the team who acts as their case manager, taking responsibility for facilitating and coordinating patient-centred care, including home visits where appropriate. Three case examples (Boxes 1–3) illustrate the pathway in action.

The development of an outreach team in Westminster appears to have improved equality of access to specialist diabetes care for people who would otherwise have remained untreated. In its first year, the outreach service has helped 30 such people to attend conventional clinics, provided education to local services, prevented numerous hospital admissions, and helped to reduce unnecessary diabetes-related distress and complications. Full analysis of the effectiveness of the service will follow in the near future.


Ciechanowski PS, Katon WJ, Russo JE (2000) Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 160: 3278–85
Department of Health, Policy and Strategy Directorate (2008) Delivering Care Closer to Home: Meeting the Challenge. DH, London. Available at: (accessed 14.03.11)
Hayward M (2007) Psychiatric morbidity and health service use among attendees at a winter shelter. The Psychiatrist 31: 326–9
Healthcare for London (2009) Diabetes guide for London. NHS, London. Available at: (accessed 14.03.11)
Hwang SW, Bugeja AL (2000) Barriers to appropriate diabetes management among homeless people in Toronto. CMAJ 163: 161–5
Koro CE, Fedder DO, L’Italien GJ et al (2002) Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study. BMJ 325: 243
Scott J (1993) Homelessness and mental illness. Br J Psychiatry 162: 314–24

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