Bridging the diabetes care gap

Why this matters

A person who lives with diabetes may need to see a family doctor, an endocrinologist, have blood work completed, undergo eye and foot screening and receive diabetes education. These appointments often take place at different locations across the city. For many people — particularly those who face various forms of social and structural disadvantage — that's simply not realistic.

Often, the challenge is not only managing diabetes, but accessing the care needed to stay healthy. Social and structural barriers can make routine care difficult or even impossible, leading to poorer health outcomes that could have otherwise been prevented. Social, economic, cultural and systemic barriers make it harder for many individuals or groups to access health-care and other support. For many people, these challenges are made worse by negative experiences in traditional health-care settings because of stigma, judgement and prejudice. As a result, their health may worsen, leading to potentially avoidable complications.

It is this systemic gap identified by Dr. David Campbell, MD, PhD, an associate professor in the departments of medicine, community health sciences and cardiac sciences at the Cumming School of Medicine, and the Calgary Diabetes Advocacy Committee, that prompted a systems-level approach to improve diabetes specialty care for those facing social and structural disadvantage.

“We always try to take a step back and recognize that it’s less about behaviour, and more about structures in which people live, many times agency is constrained by the circumstances of our lives," says Campbell.

Campbell’s research shows that people living with diabetes who face homelessness, housing instability or other structural barriers experience poorer health outcomes than those who can access routine care. The team’s research also shows they face a 63 per cent higher risk of death, twice the risk of cardiovascular disease and six times the risk of amputations.

Why does this problem exist?

One significant contributor to this disparity, Campbell says, is the siloing of health and social services such as primary health care, specialty and acute care, non-profit organizations and patient/citizen advocacy groups.

For instance, an individual could have access to quality primary care, but may find it challenging to connect with specialists, who are often based in hospitals, either because of transportation barriers or general mistrust of the health-care system rooted in a history of negative experiences.

For Campbell and his team, the services offered in these organizations are complementary to each other, and should be integrated. As a result, the Diabetes Mobile Clinic (DMC) Project was launched in July 2024 in partnership with the University of Calgary, Alberta Health Services, The Alex Community Health Centre and the Calgary Diabetes Advocacy Committee.

Rather than creating another stand-alone program, the team worked with researchers, health-system partners, community organizations and people with lived experience to develop the clinic using an approach that reflects Learning Health System principles.

“We’re trying to offer an alternate pathway,” Campbell explains. “So that by developing person-centred interventions we can reduce those barriers that exist and improve diabetes management and outcomes for people who face severe social disadvantage.”

Bringing critical services to underserved communities

Grounded in the Socio-Ecological Model (SEM) framework — which illustrates how individual health behaviours are shaped by interactions across individual, interpersonal, organizational, community and structural levels — the DMC is the first of its kind to provide Calgarians with a range of specialized diabetes care across the city.

In collaboration with The Alex Community Health Centre, the mobile clinic offers comprehensive services including on-site screening and testing, diabetes education and self-management support, specialist consultation and integrated follow-up and referrals when complications are detected.

On the mobile clinic, people with diabetes can consult with a nurse, a resource specialist liaison, a certified diabetes educator and an endocrinologist like Campbell himself, providing access to comprehensive, high-quality care.

“It’s meant to be a one-stop shop,” he says.

Campbell also identified that the distribution of diabetes and its complications are highest in the northeastern parts of the city, where the Diabetes Centre Calgary only has a small satellite clinic at Sunridge Medical Gallery/Peter Lougheed Hospital.

“In the east and northeast parts of Calgary is where there’s the greatest need, and that’s not where most [diabetes] services are currently provided.”

To address this, the DMC regularly visits community sites in East and Central Calgary, including community health centres, homeless shelters, supportive housing facilities and community recreation centres.

Going forward

Since its launch in 2024, the program has served over 250 people, half of whom had screening for diabetes and the other half who have diabetes were seen for various specialty services.

“These are, in many cases, people who otherwise wouldn't have accessed specialty-level care and [we] would have seen these folks in our emergency department because they didn't have any kind of ambulatory specialty care,” says Campbell.

“That is our hope, that we’re keeping people out of acute care by providing higher quality, specialty care in the community.”

A structured evaluation of the project is currently underway, including a qualitative study exploring patient experiences, a follow-up assessing patient-reported outcome measures, a cost-effectiveness analysis and a randomized controlled trial evaluating clinical outcomes and health-care utilization.

Findings from these will help determine whether the model should be refined, expanded and integrated into the broader health system.

How this advances a Learning Health System

✓ Identified a systemic gap in care and responded to a real-world challenge
✓ Brought together academic, community and health-system organizations to develop a solution
✓ Embedded lived experience within project governance and decision-making structures
✓ Co-designed services with patients with lived experience of both diabetes and homelessness
✓ Promoted equity by reducing access barriers and bringing care to the population most in need

Learn more about the Diabetes Mobile Clinic Project

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