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Diabetes - Clinical Brief

Why You Should Ask Certain Patients With Diabetes About Their Housing Situation

Unstable housing can help pinpoint diabetes control issues. Here is how our clinical advisors suggest raising the issue — and with whom.

Author(s): Renee Cocchi | Clinical Advisor(s): : Jane Seligson Sillman, MD; Harold H. Katz, MD, FACP, FACE | 1/11/18

You should be asking certain patients with diabetes about their housing situation because it can identify those who may have problems controlling their condition, according to a recent study. It’s a tricky issue to tackle, so we asked 2 of our clinical advisors to weigh in.

First, the study: The 2014 Health Center Patient Survey was administered to nearly 1100 non-homeless adults treated at federally funded safety net health centers. Investigators looked at self-reported diabetes-related emergency department (ED) use or inpatient hospitalization in the prior year; housing status; and use of housing assistance. Among the results:

  • 37% were considered to have unstable housing, defined as not having money to pay mortgage or rent, moving >2 times in a year, or staying with friends or relatives without paying.
  • Overall, 14% reported a diabetes-related ED visit or hospitalization in the prior year.
  • <1% reported getting housing help through their clinic.
  • Those who had unstable housing were >5 times more likely to visit the ED or be admitted as inpatients.

“This study is extremely relevant, as I can think of 2 patients right off the top of my head who I’ve seen in the past 6 to 8 months who were hospitalized for ketoacidosis for these exact situations,” said Harold H. Katz, MD, FACP, FACE, Lead Physician at Allina Health United Medical Specialties, St. Paul, MN. “And I don’t see a high-risk population, so I can imagine how common these issues are.”

When Jane S. Sillman, MD, Assistant Professor of Medicine at Harvard Medical School, Boston, thought about her patient population in relation to the study. What stood out to her was that, in some cases, patients’ housing situations were obvious but at other times they weren’t. Knowing this information would be helpful.

“This shows the importance of knowing your patients,” adds Dr Katz. “When asking patients about their medical history, primary care providers (PCPs) should include patients’ social history, too, and ask a few quick questions about their housing situation. It can be done verbally or via a checklist. We just need to get the information to identify people who are at greater risk for diabetes-related ED visits and hospitalizations.”

Since there isn’t a standard tool or guidance, it is tricky to know who to question. Dr Sillman suggests screening patients with diabetes who are using the ED or requiring inpatient hospitalization for diabetes care because they’ve already been identified as a high-risk group for being unstably housed.

“It helps you explain why you’re asking about housing,” says Dr Sillman. “Some patients may be embarrassed about their housing situation and may be reluctant to disclose it. But if you say, ‘Housing problems can make it harder for some patients to control their diabetes, so I ask all my patients who’ve needed ED care or hospitalization for diabetes about their housing situations,’ patients don’t feel singled out.”

Questions (derived from this study) that PCPs can ask in their screenings are:

  • Do you have enough money to pay your rent or mortgage?
  • Have you needed to move ≥2 times in the past year?
  • Are you staying in a place that you don’t own or rent, like a friend’s or relative’s home?

“Once patients have been identified as having unstable housing, then we need to provide them with help,” adds Dr Katz. “While most primary care practices can’t afford a social worker on staff, we can refer patients to local social workers, and maybe they can help patients with their housing situation. This would be 1 way to improve care and save money.”

Another option Dr Sillman suggests is for PCPs to call the hospitals they’re affiliated with to see if they have a social worker who would be willing to talk to their patients.

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