Publication Date: 1/12/2008
Following is a guideline for physicians, titled "Adapting your practice: treatment and recommendations for homeless patients with
diabetes mellitus."
BRIEF SUMMARY CONTENT
RECOMMENDATIONSEVIDENCE SUPPORTING THE RECOMMENDATIONS
IDENTIFYING INFORMATION AND AVAILABILITY
Go to the Complete Summary
RECOMMENDATIONS
MAJOR RECOMMENDATIONS
- Assess where the patient is 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 the patient last had a permanent or regular place to live and if they ever had their own apartment or home.
- Ask the patient about eating habits and patterns, including nutrition status, weight history, and food sources (e.g., soup kitchens). Many food sources supply only one meal a day so that the homeless person must visit multiple places for food.
- Ask the patient if they have access to food and water when they want or need it (e.g., snacks).
- Assess and often reassess how much walking the patient is doing as well as the condition and fit of footwear.
- Ask patient if they have ever had foot sores or ulcers or any problems with their feet.
- Obtain a sexual history including contraception and reproductive history.
- Ascertain the patient’s current medications and how they are obtained.
- Explore the use of tobacco, alcohol, and illicit drugs, and the frequency and route of use. Assess the patient’s readiness to change behavior.
- Assess patient’s literacy level.
- Perform dipstick urinalysis to test for ketones, glucose, protein, and sediment.
- To assess kidney status, the best test for homeless patients is the albumin-to-creatinine ratio (urine for microalbumin) in a random spot collection. If the test is elevated, repeat. If the test is again elevated, do a 24-hour urine for protein. Consideration of the patient’s living situation and ability to do the 24-hour collection must be weighed carefully before ordering this test.
- Since homeless patients can be transient, consider using a diabetic monitoring card to record labs and exams (Ridollfo & Proffitt, 2000). Patients can use this card to share information with their next health care provider, and it is also useful as a self-management tool. Designed specifically for homeless individuals with diabetes, the monitoring card is available through the Health Care for the Homeless (HCH) Clinicians’ Network (cards come 100 to a pack; for a sample or to order call 615 226-2292).
At each visit the clinician should:
- Assess the 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.
Patient Education and Self-Management
- Assess where and when the patient is eating, and the frequency and healthfulness of meals.
- Provide suitable documentation for the patient with diabetes to use at food pantries, soup kitchens, and shelters to obtain healthful snacks and foods.
- Encourage the patient 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 the patient to save part of the meal for later when only one or two meals are available per day.
- Provide multivitamins with minerals.
- Provide toothbrushes, toothpaste, and dental floss.
- Teach basic oral health care (e.g., demonstrating proper brushing and flossing).
- Advise patient to rinse mouth with water after eating when brushing is not possible.
- 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.
- Encourage patient to keep feet dry and take shoes and socks off at night.
- Instruct patient to wash socks nightly, if possible, and dry thoroughly.
- 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.
- 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.
- Secure a podiatrist for referrals and consultation.
- Consider using a basal insulin such as Lantis with Lispro insulin or regular insulin before meals to accommodate erratic eating patterns.
- Consider having the patient use a sliding scale if food sources are unreliable or unavailable.
- Consider decreasing insulin dosage when food is unavailable.
- Use premixed insulin when possible.
- If they are walking a great deal, encourage patient to inject insulin into the abdomen to avoid erratic absorption.
- Remind the patient to rotate injection sites to avoid lipodystrophy.
Since patients have little or no access to refrigeration, consider these options:
- Assess if the patient can use a shelter’s refrigerator and if the insulin will be accessible when needed.
- Store the patient’s insulin at the clinic and dispense one vial at a time.
- Suggest that the patient store insulin in an insulated lunch bag.
- Provide insulated lunch 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.
- Recommend that patients avoid carrying insulin inside pants or shirt pockets.
- Consider providing alcohol wipes to clean needles for reuse.
- 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. The patient will need to show the pharmacist their insulin supply.
- Assess liver function on a regular basis.
- Screen carefully for alcohol abuse before starting metformin due to an increased risk of lactic acidosis.
For the patient taking sulfonylureas, the clinician should:
Self-monitoring of Blood Glucose
If self-monitoring is not possible, the clinician should:
- Teach patient to use urine strips to check glucose.
- Recommend frequent clinic visits to monitor blood glucose and complications.
Tip: Urine and visual blood glucose strips can be cut in half to double the supply.
Contingency Plan for Managing Hypoglycemic Episodes
Management of Associated Problems and Complications
When considering using a diuretic for blood pressure control, the clinician should:
- Assess the patient’s access to bathroom facilities.
- Assess the patient’s access to water and other fluids if the patient is living outside in a hot climate.
For the patient who is not ready or able to abstain from alcohol use:
- Stress the importance of eating.
- 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.
- 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.
- 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.
- 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
CLINICAL ALGORITHM(S)
EVIDENCE SUPPORTING THE RECOMMENDATIONS
REFERENCES SUPPORTING THE RECOMMENDATIONS
TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS
IDENTIFYING INFORMATION AND AVAILABILITY
BIBLIOGRAPHIC SOURCE(S)
ADAPTATION
DATE RELEASED
GUIDELINE DEVELOPER(S)
SOURCE(S) OF FUNDING
GUIDELINE COMMITTEE
COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE
FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST
GUIDELINE STATUS
GUIDELINE AVAILABILITY
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