Diabetes Awareness to Reach Excellence (DARE) - Making a Difference in the Homeless

The Daily Planet, a Federally-Qualified Health Care for the Homeless Clinic, has been serving Richmond's homeless population for more than 40 years. The Daily Planet and Virginia Commonwealth University (VCU) also have an established Academic-Community Partnership. Since 2005, they have worked together to enhance medication-related health outcomes among those who experience homelessness in the Richmond community. Project ImPACT: Diabetes Awareness to Reach Excellence (DARE) - Making a Difference in the Homeless was implemented at the Daily Planet in September 2012.

The program is two tiered, one with comprehensive interdisciplinary diabetes outreach and screening and the other, with a diabetes management program. The interdisciplinary team operates within a patient-centered medical home model which includes a physician, pharmacists, nurse, dietitian, health educator, optometrist, and case manager. Outreach events will also provide education and screening for comorbid conditions such as obesity, hypertension, and hyperlipidemia.

The second tier of the program is an interdisciplinary diabetes management program. Patients are offered the opportunity to enroll in the program if they have a hemoglobin A1c > 7.0. We cover cost of medications (if needed), testing supplies, bus passes for visits, and special incentives such as lunch are offered during the visits.

Preliminary and expected outcomes are engaged, educated, healthier patients who are involved in self management of their diabetes. We expect to see long term reduction in emergency room visits, hospitalizations, increased medication adherence, and improved overall quality of life in this very fragile population.