Improving care for people experiencing homelessness with diabetes

Homelessness is a rising problem in the UK. Recent research from the charity Shelter showed that at least 309,000 people in England were homeless, including almost 140,000 children (Shelter, 2023). This included people who were rough sleeping, living in hostels or supported accommodation, and living in temporary accommodation. It represented an increase of 14% (38,100 people) in one year. These figures do not include people who are sofa-surfing or “hidden homeless” (e.g. people who are living on buses or at work).

In a systematic review of literature from 1990 to 2020, one US study indicated that up to 22% of people experiencing homelessness had some form of diabetes, and that over 40% of homeless individuals with diabetes have blood glucose levels above the healthy range (Diabetes Times, 2021). The review showed that people with diabetes who are homeless are at much higher risk of serious complications, such as amputations, and of death.

Managing diabetes whilst being homeless is a significant challenge (Grewal et al, 2021). Most homeless adults with diabetes report difficulties managing their condition, and homelessness poses numerous practical barriers (e.g. the storage of medicine, and the challenge of obtaining and preparing recommended foods). Co-existing poor mental health and addictions often present further safeguarding challenges, while literacy, language and brain injury problems and neurodiversity are also often present.

Burdett Trust for Nursing project

The Burdett Trust for Nursing has funded a year-long project aimed at improving healthcare for people experiencing homelessness with diabetes. The project has been running since April 2023, and will report formally in July 2024. It has included a survey, practitioner workshops, patient interviews and nurse-led quality improvement projects, and the profiling of existing good practice.

The project is guided by a strong steering group consisting of the authors, a diabetes consultant, specialist dietitian, specialist podiatrist, consultant optometrist, homeless health inclusion health consultant nurse and GP, and five experts by experience (i.e. people who have recently experienced homelessness). It is hosted by Pathway, the UK’s leading homeless and inclusion health charity.

Inspiration for the project

The idea for the project was inspired by the work of one of the authors, Lynne Wooff, a diabetes specialist nurse (DSN) in Bolton. In 2020, Lynne identified the need to adapt her practice and outreach into community service to meet the needs of people experiencing homelessness. A case study of Lynne’s early progress was profiled by the Queen’s Nursing Institute (QNI, 2021).

Prior to August 2020, Bolton NHS Foundation Trust’s Homeless and Vulnerable Adult Team (HVAT) had a general caseload of approximately 200 people, but there was no systematic approach to diabetes. Crisis management was common, especially for those treated with insulin, and the team often struggled to obtain responsive action from GPs, resulting in the need to ring the Diabetes Centre helpline for advice. Additionally, managers and staff of homeless hostels had no knowledge of who had diabetes, and had poor awareness of diabetes management and, more importantly, how to recognise and manage diabetes emergencies.

As a result, Lynne set up a new multidisciplinary team process, consisting of the HVAT lead, a diabetes and endocrine consultant, local diabetes community champions and their coordinator, retinal and foot screening specialists, a representative from Healthwatch, and the managers of the three main hostels and Emmaus (a charity supporting people to work their way out of homelessness). Strategy meetings have been running quarterly since.

What has been achieved in Bolton?

To identify any hidden diabetes within the local population experiencing homelessness, a point-of-care blood-testing machine (Cobas B101, Roche Diagnostics) has been sourced to screen within HVAT clinics, and is taken to the hostels on a quarterly basis. In addition, working with the emergency department clinical lead and the informatics team, lipid and HbA_1c testing has been added to the routine emergency care blood order for anyone identified as NFA (no fixed abode), and who agrees to these additional investigations.

Elevated test results are managed by Lynne and the HVAT, and the patient GPs are informed of the results and management plans.

Lynne now works with the HVAT to ensure that each person identified with diabetes is helped to receive their nine key diabetes care processes. All patients are encouraged to have a face-to-face appointment with the DSN to discuss the results and to agree a management plan through timely, flexible follow-up appointments that can be delivered on outreach. The GPs are provided with the results and the management plan. 

In addition, Bolton “Community Champions” run diabetes awareness sessions quarterly at the three main hostels and at Emmaus. They calculate Diabetes UK “Know your risk” scores, and provide information on appropriate healthy food choices and practices, and on how to keep active. Eden’s free-to-access Sanofi Cares educational programme has been promoted and made available to all hostel staff. This is an online modular course to teach diabetes awareness and management, which helps to increase their confidence in supporting anyone in their care identified as having diabetes. Uptake has been very good.

With support from the Bolton Foundation Trust’s business intelligence team, a database was developed to record demographic data, as well as all dates and results of the nine care processes, actions, follow-up dates, discharge from service dates and reasons. Since the beginning of the project, 39 people experiencing homelessness with diabetes have been supported by Lynne. The average wait to first assessment by Lynne has been 6.5 days, and 89% have had all nine diabetes care processes met.

NHS England funding has now been awarded to allow the lead DSN, Lynne Wooff, to be attached to HVAT for one day a week for 18 months. During this time, sustainability data and funding will be sought.

Progress and outputs from the national project

Both DSNs and homeless and inclusion health nurses have been recruited on to the Burdett Trust for Nursing project. Some were already undertaking innovative work in this area, similar to Lynne; for others, joining this project was the start in their quality improvement journey. These nurses will meet to share their insights on 26 April 2024, and it is hoped the project will be able to report significant improvements in care around the country.

Key insights from this project so far

• Very high risks in this population (e.g. lots of early eye and limb problems, and other complications) and the associated complex safeguarding challenges.
• A lack of routine screening in this population.
• Patients feeling “told off” when they are diagnosed and during follow-ups, while also feeling completely unable to follow advice (e.g. on healthy eating), leading to disengagement.
• Inadequate accommodation and a lack of access and ability to source appropriate food and cooking facilities.
• A comparatively high prevalence of type 3c diabetes.
• The significant improvements in care that can be achieved with outreach from DSNs and/or partnership between DSNs and homeless and inclusion health services.

Planned outputs of this project

• A project report.
• An e-learning module for nurses, allied workers, health support workers and hostel staff to be hosted on the Fairhealth website.
• A Queen’s Nursing Institute Homeless and Inclusion Health Programme clinical guidance resource for inclusion health nurses and DSNs.
• An updated Groundswell leaflet on diabetes for people experiencing homelessness. Groundswell is a homeless health peer-advocacy organisation.
• Updated Diabetes UK web pages about homelessness.
• An All-Party Parliamentary Group presentation highlighting the challenges of managing diabetes when homeless, and arguing for all people in this situation to be a priority need for housing.

Resources and organisations

Bolton Homeless and Vulnerable Adults Team (HVAT)
https://www.boltonft.nhs.uk/services/homeless-and-vulnerable-adults

Burdett Trust for Nursing
https://www.btfn.org.uk

Community Champions, Bolton
https://letskeepboltonmoving.co.uk/communitychampions

Diabetes UK
https://riskscore.diabetes.org.uk/start

Emmaus
https://emmaus.org.uk

Fairhealth
https://www.fairhealth.org.uk/courses

Groundswell
https://groundswell.org.uk

Healthwatch
https://www.healthwatch.co.uk

Pathway
https://www.pathway.org.uk

Sanofi Cares
https://www.edendiabetes.com/education-blog/sanofi-cares

Shelter
https://www.shelter.org.uk

The Queen’s Nursing Institute
https://qni.org.uk