The night before Halloween 2008, Ann Lewis, BSN, RN, roamed the streets of Pittsburgh with a bag filled with popcorn, brownies, candy and fruit. She was not getting a jump start on trick-or-treating, but doing what she has done every Thursday night for the past 8½ years - volunteering with Operation Safety Net.
The medical outreach program affiliated with Pittsburgh Mercy Health System became one of the nation's first full-time street-medicine programs in 1993 and continues to set the standard for this unique form of healthcare. As a clinician volunteer, Lewis touches base with people living in the city's parks, under bridges and on the streets to ensure they have food and their healthcare needs are met. Alongside the food in the bag she carries are medical supplies - non-narcotic pain medications, blood pressure medications and antibiotics, to name a few.
On this particular night, Lewis, traveling with a shelter volunteer who used to be homeless himself, encountered a few of the many homeless people she has seen throughout the years who have diabetes. When she sees them, she'll test their blood sugar levels, give them a blood glucose monitor if they don't have one already and make sure they have something to eat.
"Two of them, one woman and one man, both with diabetes, use their glucose monitors regularly," Lewis said. "One of the men, Johnny, will check his and when it's over 200, he says he'll watch his diet.
"Another man is going to be going on insulin. For that, he can come to the shelter to get presealed syringes and to take his insulin," she added. When he leaves the shelter for the day, however, controlling his disease becomes another challenge he'll face.
One More Hurdle
A 2007 study from the National Law Center on Homelessness and Poverty found 3.5 million people living in the U.S. are likely to experience homelessness in a given year. Homelessness places people at high risk for a variety of communicable diseases, infections and trauma injuries as victims of violence.
Life expectancy for a person without a home is 45-49 years, according to the National Health Care for the Homeless Council. The agency also reports the No. 1 cause of death among this population is complications related to chronic disease, like diabetes.
"It's hard enough to be homeless. Throw in diabetes, and it's just one more hurdle for them," said Kathy Monteith, RN, CDE, coordinator of the Diabetes Resource Center at St. Joseph's Health Services of Rhode Island, Providence. For the past 17 years, the Diabetes Resource Center has treated people who are homeless, as well as people with homes who are uninsured and underinsured, getting them the necessary medications and social services needed to control their disease.
The first thing Monteith and her colleagues do for a homeless person who comes in for diabetes management is to find out whether or not he or she is staying at a shelter. If not, they'll line up one where the person can sleep.
Once they get into their shelters, the patients will receive everything they need to manage their disease: insulin, syringes, glucose monitors and test strips, Monteith said. But here lies a major hurdle for diabetes management. Once at the shelter, patients are advised not to keep their supplies with them. Insulin goes in the refrigerator, and medications, monitors and test strips are locked up, usually in the office area to prevent theft. Medical supplies, especially those for diabetes management, are often stolen from people with diabetes and sometimes the patient will sell them on the street.
"If they need to leave the shelter early in the morning, they have to get into the office to take their medication for the day, and sometimes the person who has the keys isn't there or someone can't find them," Monteith said. "Although it is for their physical well-being to be compliant, there is this round of stresses that prevents them from getting better and getting better blood sugars. Then, they end up not in a healthy place."
Monteith offers advice, suggesting to patients how they can safely keep their medications on them during the day and calling shelters to explain the need for someone to have access to their medications. "We advocate for them. We might recommend people try one shelter over another in some cases, but it's simply a matter of these places not having enough people and resources."
One of the most vital aspects to controlling diabetes - nutrition - is taxing for all patients, but for people without homes to go to, it's nearly impossible.
"When they go to the soup kitchens or shelters for their meals, they're not thinking about portion control," Lewis said. "They'll often say 'I overate because I wasn't sure where or when I would eat next.'"
Still, the ones who have diabetes will mind their low-calorie diet when Lewis brings along candy and fruit on her volunteer missions with Operation Safety Net. "They surprisingly make smart choices," she said. "Bananas are very popular. They're good for you, and with a lot of the homeless and diabetes patients having teeth problems, they're a good option."
Soup kitchens and shelters try to make available healthy food options, but again, Monteith said, it's a matter of resources. "It's coffee, doughnuts and juice, or nothing. What is your choice going to be?"
Homeless shelters and soup kitchens in the Venice, CA, area have called Claudia Ramirez, FNP, CDE, nurse practitioner at Venice Family Clinic, to educate their staffs about cooking for people with diabetes. "I'll tell them to make sure they always have vegetables available. Instead of serving Kool-aid, water is better. Don't fry the food, grill instead. Choose poultry, like chicken and turkey, over red meat."
For breakfast, as budget-friendly as sugary pastries like doughnuts are, oatmeal is a much better option, Ramirez tells the food-service staff. "Oatmeal is great for the fiber, plus it is good for people who don't have teeth," she said.
In the past year, of the 3,960 homeless patients who were treated at Venice Family Clinic, which also treats uninsured and underinsured people who have places to live, 278 had diabetes. A lot of the people who seek treatment for their diabetes do so because related complications have worsened, Ramirez said.
"We see a lot of ulcers, mainly on the feet, some amputations, abscesses, teeth problems, blindness, heart problems," she said. "We're constantly doing dressing changes on these foot wounds that won't heal. The infections are so severe because they don't have a home to sit down and put their feet up at. They don't have a place to bathe their feet. They're walking miles and miles each day."
An electronic medical record database the Diabetes Resource Center in Rhode Island keeps on its uninsured and underinsured patients reveals 650 have diabetes, Monteith said. When cross-referenced with other chronic diseases like hypertension or hyperlipidemia, 550 people with diabetes have been identified.
A key point to keep in mind, she added, is chronic diseases usually don't travel solo. Any patient with diabetes in any living situation can be perfect with the diet, medication and exercise but can still face a high risk of having heart attacks and strokes.
"You can take care of yourself, but it doesn't take away that risk factor 100 percent," Monteith said. "But just think how much easier it is to care for yourself when you're not in this constant routine of finding a place to sleep and eat."
Teaching & Listening
At Venice Family Clinic, a weekly diabetes class is offered to all patients, homeless or otherwise. Here, Ramirez and her colleagues provide further information for patients with diabetes.
"Some of them have had diabetes for years, and others are newly diagnosed. We talk about what diabetes is, how to start insulin and go over how to use all the medications and supplies," she said.
A nurse to the core, Lewis, who works full-time in the interventional radiology department at St. Clair Hospital in Pittsburgh, educates during her volunteer work.
"I'll ask if they're feeling numb anywhere, and make sure any nonhealing wounds are seen," she said. "We'll tell them to keep any cuts they have as clean as possible. If they're having any blurred vision, their blood sugar is probably too high. They're pretty good at telling us what they need and following up about any concerns to their health.
"The results surprise me," Lewis added. "My mother just passed away after 10 years with diabetes. Some of the homeless people I see are more compliant than she was."
Taking the initiative to understand their disease and be compliant helps, but the very nature of being homeless works against a lot of their hard work, Ramirez said.
"Some are compliant, some aren't. Most find it challenging. They're always on their feet. They're not in control of their food. They move around a lot. And their main priority is to stay warm."
Monteith finds the simple act of listening does wonders for patients who are homeless. "A lot of them just can't figure out how to feel good about themselves," she said. "But, here, they have a place to come to for their healthcare needs and for someone to just listen to them. Being treated with respect gets the endorphins flowing and the sugar will get better."
Stacey Miller is associate editor at ADVANCE