Diabetes care for people experiencing homelessness: A UK national survey & integrated care model

Background: People experiencing homelessness (PEH) face unique barriers to diabetes management including unstable housing, food insecurity, and fragmented services. This study aimed to understand frontline professionals' perspectives on diabetes care for PEH and develop an evidence-based integrated care model.
Methods: We conducted a mixed-methods cross-sectional survey (January-April 2024) of UK healthcare and voluntary sector professionals managing diabetes in PEH. The survey assessed perceived diabetes prevalence, complications, care quality, and management strategies. Quantitative data (n=104) were analyzed using ANOVA, Kruskal-Wallis tests, and ordinal logistic regression. Qualitative responses underwent thematic analysis. Findings were triangulated to develop the Integrated Holistic Diabetes Care Model for Homelessness (IHD-CMPH).
Results: Respondents included specialist diabetes clinicians (31%), homelessness/inclusion-health staff (38%), and voluntary sector providers (32%). The median perceived Type 1 diabetes prevalence among PEH was 20% (vs 8% nationally, p<0.001). Most (57%) rated diabetes outcomes for PEH as poor/very poor, with 66% reporting increased complications including amputations and vision loss. Key predictors of better outcomes included clear organizational policies (OR 1.62, 95%CI 1.06-2.48), cross-sector collaboration (OR 2.76, 1.20-6.36), and outreach-specific training (OR 2.50, 1.50-4.17). Major barriers identified were service fragmentation, inflexible appointments, and insufficient homelessness-specific education (87-96% lacked training).
Conclusions: Diabetes inequities among PEH stem from modifiable structural failures rather than patient non-adherence. The IHD-CMPH framework integrates four components: 1) assertive community-based clinical delivery, 2) organizational integration addressing social determinants, 3) trauma-informed workforce development, and 4) digital inclusion with monitoring systems. This evidence-based model provides actionable strategies to operationalize inclusion-health policy and advance health equity for this underserved population.