April 2016

In this Issue: Working to End Homelessness among Veterans
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Palliative Care for Homeless Veterans

Ongoing study

Among the homeless, mean age at death ranges from 34 to 47 years, and being a Veteran is associated with a 1.7 increased odds of death. As more homeless Veterans enter VA-supported housing, VA will need to provide for more of their medical and psychological needs, which are likely to grow exponentially as they age. Care for homeless Veterans, and for those at the end of life (EOL), are VA priorities; however, Veterans who are both homeless and at EOL do not fit easily into the programs designed for either group. This ongoing study describes the challenges associated with caring for homeless Veterans at the end of life, as perceived by VA medical center leadership, homeless care and EOL care staff, and most importantly, by chronically ill Veterans with unstable housing. Investigators surveyed 50 VA EOL and homeless Veterans' programs to better understand what services are currently targeted for homeless Veterans at EOL. Based on survey findings, four sites that identified themselves as having significant homeless populations with EOL needs, in places where programs for homeless people who are at EOL may already exist and which are geographically dispersed, were chosen to host a multi-day site visit during which key informant interviews and focus groups were conducted to ascertain issues, barriers, and facilitators of EOL care. A total of 29 Veterans, 19 leaders, and 88 focus group members participated in the site visits.

Findings

Personal, clinical, and structural challenges are presented to care providers for Veterans who are homeless at the end of their lives. The surveyed VAMCs treated an average of six Veterans at EOL annually, but site visit participants thought this underestimated the number of Veterans in this category. Lack of appropriate housing for Veterans with predictably declining functional status was cited as the most critical challenge. Other important challenges include:

• Symptom management within the context of addiction, such as unstable housing and behavioral health problems;
• Discontinuity of care between and within systems; and
• VA regulations that pose significant barriers to collaboration with community providers.

Dedicated homeless and EOL program staff collaborate informally to overcome many of these challenges as best they can.

In the final phase of the study, a National Program and Policy Development Forum - comprised of national leadership and focus group representation from each city - was convened. Draft recommendations from the Forum include:

• Better translation and dissemination of existing policy;
• Policy changes designed to enhance flexibility and facilitate access to housing and care;
• Cross-system and cross-silo-of-care education;
• Facilitating communication networks among VA and community, homeless and EOL providers; and
• Select pilot program testing.

Impact

The Forum has laid the groundwork for leaders in all arenas to begin breaking down communication barriers between the silos of palliative care and homeless care within VA, and among VA and community providers, so that more sustainable collaboration can improve care for those who have borne the brunt of America's wars over the past 50 years.

Principal Investigator: Evelyn Hutt, MD, HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care, and the VA Eastern Colorado Health Care System, Denver, CO.

Hutt E, Whitfield E, Min SJ, et al. Challenges of providing end-of-life care for homeless Veterans. American Journal of Hospice & Palliative Care. American Journal of Hospice and Palliative Medicine. May 2015;33(4):381-389.