People with serious mental illness are genetically predisposed to diabetes. Their risk is heightened with the use of atypical antipsychotic medications. Contextual conditions also influence diabetes care and outcomes. There is a lack of research on diabetes care for the mentally ill in residential care facilities. Therefore, there is little understanding of the social relations that contribute to this group’s health disparities. Institutional ethnography was chosen to explore this phenomenon in a group of 26 women in a rural for-profit group home in southern Ontario. Work activities of residents and providers were examined to map out the social organization of health inequities. Interviewees included residents with diabetes, care providers, field workers, and health professionals. Observations and analysis of coordinating texts were further methods used to reveal disjunctures between discourses embedded within diabetes care guidelines and the actualities of living within imposed constraints of group home care. The overarching State interest in cost containment creates rationing that limits the care afforded residents, resulting in poor dietary intake and lack of quality of life opportunities. Further, group home policies regulate systems of safety, reporting, and financial accountability, but do not promote health. The medical and psychiatric divide also contributes to health disparities. Diabetes care provision supports ‘self-care,’ which is challenging for this group, and health providers lack understanding of contextual constraints. Combined, these social circumstances perpetuate disease development and make illness management difficult. These findings warrant the need for State financial support and policy changes that give primacy to illness prevention, health promotion, and medical management so the mentally ill can realize health and wellbeing. A linkage between mental and physical health care is also crucial. Further, health providers are urged to be critical of social ideologies that sustain health inequalities, and to deliver services that are sensitive to unique particularities.

People with serious mental illness are genetically predisposed to diabetes. Their risk is heightened with the use of atypical antipsychotic medications. Contextual conditions also influence diabetes care and outcomes. There is a lack of research on diabetes care for the mentally ill in residential care facilities. Therefore, there is little understanding of the social relations that contribute to this group’s health disparities. Institutional ethnography was chosen to explore this phenomenon in a group of 26 women in a rural for-profit group home in southern Ontario. Work activities of residents and providers were examined to map out the social organization of health inequities. Interviewees included residents with diabetes, care providers, field workers, and health professionals. Observations and analysis of coordinating texts were further methods used to reveal disjunctures between discourses embedded within diabetes care guidelines and the actualities of living within imposed constraints of group home care. The overarching State interest in cost containment creates rationing that limits the care afforded residents, resulting in poor dietary intake and lack of quality of life opportunities. Further, group home policies regulate systems of safety, reporting, and financial accountability, but do not promote health. The medical and psychiatric divide also contributes to health disparities. Diabetes care provision supports ‘self-care,’ which is challenging for this group, and health providers lack understanding of contextual constraints. Combined, these social circumstances perpetuate disease development and make illness management difficult. These findings warrant the need for State financial support and policy changes that give primacy to illness prevention, health promotion, and medical management so the mentally ill can realize health and wellbeing. A linkage between mental and physical health care is also crucial. Further, health providers are urged to be critical of social ideologies that sustain health inequalities, and to deliver services that are sensitive to unique particularities.