Facilitators and Barriers in Serious Illness Care for Unhoused Older Adults

Background and Purpose:

Older adults experiencing homelessness (OAEH) face access barriers to quality and consistent healthcare, higher comorbidities, and earlier mortality compared to their housed counterparts. The spatial trajectories of OAEH with serious illnesses often includes frequent healthcare transitions between unsheltered or temporary shelters and the emergency room, dying in housing care systems or hospitals, or dying unsheltered. These disparities in health outcomes and processes of care indicate a continued lack of resources and inadequate models of care delivery. As the shortage of palliative care clinicians continues to grow, innovative solutions using homelessness service professionals and existing systems are needed. To accomplish this, there must be a deeper understanding of processes, resources, and services that currently exist for seriously ill OAEH. This study sought to explore facilitators and barriers to OAEH receiving serious illness care from the perspectives of homelessness service professionals and OAEH with serious illnesses.

Methods:

This study was a part of a multi-phase qualitative study design to adapt the Serious Illness Communication Guide (SICG) developed by Ariadne Labs for use with OAEH. This presentation focuses on the secondary aim to describe the experience of providing and receiving serious illness care with OAEH. Two groups were interviewed: OAEH and homeless service professionals (e.g., social workers, nurses, and non-clinical professionals). Data were collected via a cognitive interview with OAEH participants and two semi-structured interviews with homelessness service professionals. In addition to exploring SICG adaptations, inquiry included how homelessness service professionals addressed serious illness needs of OAEH, what resources were available to them, and how OAEH navigated and received healthcare. Reflexive thematic analysis protocols for coding, transcript summaries, and data matrices guided the research team in observing patterns in the data.

Results:

The final sample included a total of 21 participants: 11 OAEH (six White, five Black) with a mean age of 61, and 10 professionals (eight White, 1 Black, 1 Bi-racial) with an average 8.9 years of practice experience. Interviews lasted an average of 72.5 and 63.5 minutes, respectively. Both participant groups described substantial service and resource gaps related to serious illness care for OAEH. Moreover, they expressed frustration around limitations of service eligibility for OAEH. System bias and experiences of discrimination also prevented OAEH from accessing quality care. Homelessness service professionals described efforts to advocate, broker, and allocate resources, while navigating their job descriptions, licensure scope of practice, and work responsibilities. Four dominant themes emerged related to facilitators and barriers to serious illness care for OAEH: 1) OAEH resourcefulness and self-care management, 2) healthcare professionals’ negative attitudes and system bias towards OAEH, 3) scope of practice limits of homeless service professionals and 4) few available services and resources.

Conclusions and Implications:

Developing innovative and effective solutions to address the unique healthcare needs of seriously ill OAEH will require collaborations with healthcare and homelessness service professionals in the areas of social work research, education, and advocacy. The wide dissemination of this work has prompted additional projects with housing care system directors and interprofessional and multidisciplinary researchers and clinicians.