Reimagining Supportive Care for the Homeless: Aging, Disability & Serious Illness in Temporary Housing

The shifting age demographics of those experiencing homelessness in the United States have exposed shortcomings and barriers within homelessness response services to adequately address serious illness, disability, and aging among residents. This paper’s objectives were to (1) illustrate barriers to care in temporary accommodations: medical respite, Tiny Homes/Villages, congregate emergency shelters, and voucher-procured hotel rooms; and (2) identify potential strategies for increasing continuity of care with older service users. A critical realist grounded theory approach was taken through a partnership with the only specialty palliative care program for people experiencing homelessness in the United States. Researchers iteratively collected three sources of data: qualitative and quantitative medical chart data of the active rosters of specialty palliative care team from spring 2019, 2020, and 2021 (n=75); semi-structured interviews with a purposive theoretical sample of healthcare and homelessness service providers (n=30); and field notes collected during observation of the specialty palliative care team's meetings between July-November 2021 (n=12). Findings indicated facilitators in temporary accommodations for continuity of care for older unhoused people, including relative privacy and autonomy, peer support and kinship care, staff knowledge of trauma and harm reduction, and environmental adaptability and modularity. Barriers that presented were physical accessibility barriers, staff lack of awareness of aging and healthcare resources, programmatic restrictions, historical institutional trauma that promoted healthcare reticence, and challenges to establishing ‘at-home’ healthcare. Potential advances across these four temporary accommodations include incentivized interdisciplinary training, cross-system consultation models, accessibility toolkits, and adaptation of “high acuity, low barrier” temporary models for longer-term residence. Researchers can contribute implementation science expertise to measure outcomes related to continuity of care in temporary accommodations, and help translate existing temporary models that allow for co-located health and housing support into sustainable solutions for older people.