Effectiveness of the Diabetes Homeless Medication Support (D-HOMES) program on diabetes management

Among the millions of Americans who experience homelessness yearly, thousands die prematurely from diabetes. They do so at a rate that is 3 to 6 times higher than the general population. The federal definitions of homelessness include people staying in shelters or subsidized housing, sleeping outside, or “doubled up” in shared housing without being named on the lease. Although diabetes prevalence is similar to their stably housed peers, rates of glycemic control are lower and outcomes are worse among those living with type 2 diabetes who have experienced homelessness. Our team identified key individual and structural barriers to glycemic control for people experiencing homelessness including medication access and adherence, psychological distress, and competing demands (e.g., shelter, safety, and food). Medication adherence is a key modifiable health behavior that can rapidly improve glycemic control. Using the ORBIT model of behavioral treatment development, our research team (including people with relevant lived experience) has developed and pilot tested the Diabetes Homeless Medication Support (D-HOMES) program, a tailored program of behavioral support for English and Spanish-speaking people living with type 2 diabetes who have experienced homelessness. D-HOMES offers up to 10 one-on-one sessions weekly over 3 months with a health coach using behavioral activation to improve diabetes medication adherence and psychological wellness. Coaches also refer participants to local housing, food, behavioral health, and related resources. Our team’s long-term goal is to reduce premature diabetes-related mortality among people who have experienced homelessness. In this study we now propose the next step of the ORBIT model, a type 1 hybrid effectiveness/implementation randomized trial fully powered on glycemic control with 256 participants. Aim 1 (primary outcome) will test the effectiveness of D-HOMES vs. enhanced usual care ([EUC], a single brief diabetes educational session) on glycemic control among adults living with type 2 diabetes who have experienced homelessness. Aim 2 (secondary outcomes) will test the effectiveness of D-HOMES vs. EUC on long-term glycemic control, medication adherence, psychological wellness, and diabetes distress and explore moderators of treatment effectiveness. Aim 3 will complete a mixed methods evaluation using the RE-AIM model to assess the implementation-relevant features of D-HOMES (e.g., reach, adoption, implementation) for future scalability. If effective for improving glycemic control, D-HOMES could directly impact public health through scaling within the HRSA-funded national network of Health Care for the Homeless programs. Furthermore, D-HOMES can inform adaptation of other evidenced-based practices to meet the needs of other populations with access barriers and/or other chronic health conditions among people who experience homelessness.