The long-term objective of this project is to reduce the diabetes health disparities of people with type 2 Diabetes who experience Homelessness, herein abbreviated as DH. The study will focus on diabetes medication adherence as a modifiable behavior known to correlate with glycemic control, all-cause mortality, all-cause hospitalization, and health care cost.
The aims are to: (1) Develop the initial Diabetes Homeless Medication Support (D-Homes) treatment manual through focus groups with DH (N=30) at various levels of glycemic control (HgA1c<7, 7-9, >9) and interviews with their multi-disciplinary providers (N=12), (2) Test patient perceptions of the feasibility and acceptability of study procedures and refine the D-Homes treatment manual through test cases (n=10), and (3) Conduct a pilot randomized control trial (N=54) to compare the effect of D-Homes (weekly phone/in-person sessions over 12 weeks) vs. enhanced standard care (identify/reinforce care team, printed educational materials) on medication adherence, glycemic control, and health care utilization.
These aims follow a sequential exploratory mixed methods approach. Qualitative focus groups and interviews will gather data about the values, preferences, and barriers to medication adherence faced by DH and their response to proposed intervention components. The initial protocol will be developed using existing evidence-based models and interventions to improve medication adherence, specifically the Information Motivation Behavioral Skills and Collaborative Care Models and use of motivational interviewing as a counseling style. It will also include explicit support for housing, food access, and other psychosocial needs. We will further tailor our protocol by conducting ten test cases. A final protocol will be developed by integrating qualitative and quantitative findings from Aims 1 and 2 with input from a multi-stakeholder panel with providers and community members with lived experience of these issues and the mentorship team. This project will prepare Dr. Vickery for a career as an independent investigator focused on overcoming diabetes and other health disparities among historically disadvantaged groups. Her career development plan includes training goals to: (i) develop tailored, theory-based behavioral interventions to address the needs of vulnerable groups using mixed methods data, (ii) learn to conduct rigorous behavioral trials and statistical methods for analyzing results, (iii) learn to develop and use measures of patient-centered outcomes and medication adherence, (iv) advanced manuscript and grant-writing skills. The research will be conducted in an ideal environment, Hennepin County Medical Center, the largest safety net health care system in the region, and its research arm, the Minneapolis Medical Research Foundation. It will be further strengthened by Dr. Vickery?s appointment as an Assistant Professor at University of Minnesota, a large academic health center with a Clinical Translational Sciences Institute. The interviews and trial will be conducted at shelters in close collaboration with Hennepin County Health Care for the Homeless clinics where Dr. Vickery works clinically.
People with diabetes who are homeless die of preventable chronic diseases, including diabetes, at younger ages than their housed peers. Medication adherence is a modifiable behavior linked to improved mortality and diabetes-specific and overall health outcomes. The proposed work aims to design an intervention tailored to the needs of people with diabetes experiencing homelessness based on motivational interviewing and psychosocial support to improve adherence.
