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2015 HSR&D/QUERI National Conference Abstract

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1052 — Challenges of Providing End of Life Care for Homeless Veterans

Hutt E, VA Eastern Colorado Health Care System; Jones J, College of Nursing, University of Colorado; Albright K, School of Public Health, University of Colorado; Weber M, College of Nursing, University of Colorado; O'Toole TP, Providence Rhode Island DVAMC; Levy CR, VA Eastern Colorado Health Care System; Whitfield E, VA Eastern Colorado Health Care System; Min SJ, Division of Health Care Policy and Research, Department of Medicine, University of Colorado;

Objectives:
More than 76,000 Veterans are estimated to be homeless on any night. Among the homeless, mean age at death is 34 - 47 years. Although there are robust VA programs for homeless Veterans and for those at the end of life (EOL), Veterans who are both homeless and at EOL do not fit easily into either program type. This ongoing study seeks to understand the breadth and depth of unmet need for EOL care among homeless Veterans and the barriers and facilitators to providing them excellent EOL care.

Methods:
Using a mixed methods sequential design, we surveyed VA homeless and EOL programs. Based on survey findings, four geographically dispersed VA facilities were chosen for in-depth visits, where we conducted key informant interviews and focus groups with Veterans, multidisciplinary providers, and community and VA leadership.

Results:
Fifty of 152 VAMCs (33%) completed the email survey. VAMCs treated an average of 6.5 homeless veterans at EOL annually. Lack of appropriate housing was considered the most critical challenge. Interviewees and focus group participants emphasized: (1) In spite of homeless Veterans' declining health, which prevents independent living or realistic plans to abstain, current housing options are too often limited to places that insist on functional independence and a 'clean and sober' lifestyle. (2) Pain management within the context of addiction, unstable housing and behavioral health problems is challenging. (3) Discontinuity of care between systems restricts EOL care delivery. (4) VA regulations pose significant challenges to collaboration with community providers, to the detriment of frail, vulnerable homeless Veterans. (5) Dedicated homeless and EOL program staff collaborate informally. (6) Promising care models include maximization of VA-community partnerships and use of peer support by formerly homeless Veterans.

Implications:
Personal, clinical and structural challenges face care providers for Veterans who are homeless at EOL. Among the most pressing challenges are lack of housing suited to homeless Veterans with rapidly declining health, and isolation of homeless and EOL providers from each other.

Impacts:
During the study's final year, a National Program and Policy Forum will bring together select focus group participants with national VA palliative and homelessness care leadership to develop policies, collaborations and programs to facilitate high quality EOL care for homeless Veterans.