Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
A novel integrated, community-based service to improve diabetes care for people with diabetes who experience housing instability including homelessness.
Dates: February 2024 - February 2026
Implementation sites: Princess Alexandra Hospital
Partnerships: Micah Projects, Inclusive Health
This project was presented as a Poster at CEQ Showcase 2026 (PDF, 557KB).
Aim
The Diabetes Street Hub aims to improve outcomes for people with diabetes who face housing instability including homelessness by reducing barriers, enhancing care access and adopting a person-centred approach to patient management.
Outcomes
- The service has been successful in implementing a more accessible, community-based health care model for people who experience housing instability including homelessness supporting over 100 patients since its inception
- The service is designed to offer a holistic, agile and patient-centred approach to support a population with complex medical and social needs that often face significant barriers to care and adverse outcomes
- The service also provides support for hospital and community-based health teams by offering referral pathways for long-term community follow-up
- Last, the Diabetes Street Hub supports communities through pro-active community engagement, education and screening. This includes a community diabetes screening program launched in June 2025.
Background
Diabetes mellitus (DM) is a prevalent chronic condition that requires complex, multidisciplinary management and strong patient engagement and self-management skills to prevent severe complications. This is challenging at the best of times, but exceedingly difficult for people who are faced with housing instability including homelessness.
Homelessness is associated with excessively high rates of morbidity and mortality in comparison to the general population [1, 2]. Cross-sectional studies have shown a high burden of chronic disease in this group [3]. The combination of homelessness and DM is particularly disadvantageous. Type 2 DM has been identified as an important driver for the increased mortality seen in the homeless population [2]. Housing instability has a negative impact on glycaemic control [4] and is associated with an increased risk of diabetes-related emergency department (ED) presentations and hospitalisations [5]. Other studies suggest a relationship between food insecurity and the occurrence of cardiometabolic conditions and risk factors including DM [6, 7].
Further contributing to poor health outcomes, homeless people often face significant barriers in accessing effective health care. Personal and systemic factors play a role, including financial constraints, such as inability to afford medications or healthy food, competing needs and priorities, psychiatric co-morbidities, reduced access to transport and communication, lack of medication security, fragmented care and care avoidance not in the least due to significant stigma around mental health and homelessness [8]. Cultural and social determinants, including stigma, language barriers, and distrust of healthcare systems, further exacerbate these challenges.
These barriers increase the risk of delayed diagnosis, poor glycaemic control and diabetes-related complications such as neuropathy, retinopathy, and cardiovascular disease.
Although the complex care needs of this population are well-known, traditional healthcare models are often unable to engage this population effectively leading to suboptimal care and poor outcomes. Many homeless patients are frequent presenters to acute care facilities, but these encounters are often ineffective in meeting their complex care needs and result in significant pressure on and costs for the health care system [8].
A model of care that is flexible, patient-centred, solution-focused and accessible and that recognises the complex medical, psychological and social context is needed to improve diabetes care and outcomes for this vulnerable population.
Methods
The Diabetes Street Hub was established as a partnership between Metro South Health, Micah Projects - a not-for-profit, community-based organisation that provides services and support for people in need - and Inclusive Health, a primary care clinic for vulnerable people. The goal of the service is to deliver better outcomes for patients through better care access, a patient-centred approach, timely detection and management of complications, and pro-active community engagement.
The service has received funding from Queensland Health. After an initial pilot in 2023, the project was fully implemented in 2024 when funding became permanent, providing for a Clinical Nurse Consultant (CNC), a part-time endocrinologist and administrative support.
The Diabetes Street Hub has three key elements:
- A community-based Diabetes CNC: Our senior nurse is based in Inclusive Health (South Brisbane) and performs clinic-based assessments, community outreach (e.g. to temporary accommodation, supported living facilities and day drop-in centres), and hospital in-reach to facilitate early community follow-up after hospitalisation. Our CNC works closely with the lead-Endocrinologist for the service, primary care providers, and other community health and social workers
- A GP and specialist co-led diabetes clinic: people with complex diabetes are seen in a GP/Endocrinologist co-led clinic at Inclusive Health. These monthly clinics adopt a case-conference model including the patient (often supported by a support or case worker), a GP, an Endocrinologist and our Diabetes CNC. This model encourages a holistic approach and ensures broader needs and barriers are recognised and addressed.
- Proactive community outreach and education: to raise awareness about diabetes, build partnerships with relevant services and organisations, and facilitate pro-active case detection and screening, the following initiatives have been developed:
- Attendance at community events, most notably Homeless Connect – a (bi-)annual event organised by the Brisbane City Council where services and organisations can connect with the community. We have been a regular attendee at this event
- A community diabetes screening program: we organise screening events to screen people for (pre-)diabetes and assess their cardiovascular risk factors to better understand the burden of diabetes in this population, facilitate early detection, and connect people at risk with appropriate careThe Diabetes Street Hub is not bound by a defined catchment area and all eligible patients from within Metropolitan Brisbane can be referred into the service. Patients are referred to our service by GPs (often from Inclusive Health), community nurses and other health workers, hospital-based endocrine teams and emergency departments.
Our model builds on existing programs from Micah Projects to improve health care and service delivery to people at risk of homelessness. This strong connection with other programs is critical to link our service with the broader framework of care delivery to this population. We have held two stakeholder meetings to seek feedback and input from relevant experts, such as hospital representatives from emergency and endocrine departments, community nurses and nurse navigators, experienced diabetes educators and representatives from primary care, including the Primary Health Networks.
Discussion
1. Funding:
Receiving permanent funding from Queensland Health in recognition of the complex care needs, and barriers to care that exist within the healthcare system for this population has been a key to success.
2. Design:
The community partners in this project – Micah Projects and its associated primary care service Inclusive Health – have extensive experience in this field and a broad community reach which were essential in designing a model that is fit-for-purpose.
3. Collaboration and co-location with other services and programs:
Our service links with existing services and programs. Our CNC works closely with health professionals and other providers across hospital and community services including social workers, nurses, support workers, podiatrists and mental health and addictions teams. We have established relationships with relevant organisations which has resulted in referrals from multiple sources.
4. A pro-active, flexible and patient-centred approach:
To facilitate patients' needs, diabetes education is provided across community settings including Inclusive Health, drop-in centres, crisis and transitional housing, and street outreach locations. Patients are case managed by the CNC and complex cases are seen in the combined GP/Endocrinologist clinic. Where needed, patient-centred solutions are sought including use of continuous glucose monitoring, point-of-care testing, medication rationalisation, and ad hoc financial assistance with medications and diabetes consumables.
Health outcomes for this population are exceedingly poor as shown by excessive mortality rates observed in our cohort reflecting their high burden of chronic illness and complex circumstances. Although a step forward, a dedicated diabetes service for homeless does not alleviate all existing access problems. For instance, the missed-opportunity-to-treat rate is still substantial. Success cannot always be measured on a population level but may start with making a difference for individual patients. A change in narrative around homelessness is needed. Where homeless patients are often seen as “difficultâ€, they are in fact resilient people who are trying to manage life despite the multiple challenges they face. Homeless people frequently encounter significant stigma which exacerbates shame, mistrust and care avoidance [9]. Trust and a safety are essential, which requires patience, persistence, empathy and compassion.
Diabetes is our primary focus, but many patients have multiple chronic conditions and sometimes competing health needs. Our model could be successfully applied to other chronic illnesses that are prevalent in people with unstable housing.
Eventually, we should work towards a holistic chronic disease model. Care fragmentation is a likely contributor to poor outcomes, and the health system is not well-set up to mitigate this. Adopting a chronic disease-focused, rather than disease-specific approach is likely to enhance sustainability, scalability and patient outcomes.
The following next steps are being developed:
- Expand specialist outreach: addition of specialist outreach clinics to shift care delivery into the community for people unable to attend clinic appointments in response to identified challenges with attendance
- Structured debrief / case conferencing sessions with GPs to support upskilling, shared-decision making and hand-over to strengthen care
- A qualitative study into patients' care needs and barriers to care to improve service delivery
References
1.Aldridge, R.W., et al., Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet, 2018. 391(10117): p. 241-250.
2.Calvo, F., et al., Mortality Risk Factors for Individuals Experiencing Homelessness in Catalonia (Spain): A 10-Year Retrospective Cohort Study. Int J Environ Res Public Health, 2021. 18(4).
3.Lewer, D., et al., Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England. BMJ Open, 2019. 9(4): p. e025192.
4.Axon, R.N., et al., Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus. J Gen Intern Med, 2016. 31(11): p. 1331-1337.
5.Berkowitz, S.A., et al., Unstable Housing and Diabetes-Related Emergency Department Visits and Hospitalization: A Nationally Representative Study of Safety-Net Clinic Patients. Diabetes Care, 2018. 41(5): p. 933-939.
6.Te Vazquez, J., et al., Food Insecurity and Cardiometabolic Conditions: a Review of Recent Research. Curr Nutr Rep, 2021. 10(4): p. 243-254.
7.Gu, K.D., K.C. Faulkner, and A.N. Thorndike, Housing instability and cardiometabolic health in the United States: a narrative review of the literature. BMC Public Health, 2023. 23(1): p. 931.
8.Davies, A. and L.J. Wood, Homeless health care: meeting the challenges of providing primary care. Medical Journal of Australia, 2018. 209(5): p. 230-234.
9.Purkey, E. and M. MacKenzie, Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care. Int J Equity Health, 2019. 18(1): p. 101.
Key contact
Dr Pieter Jansen
Senior Medical Officer
Metro South Hospital and Health Service