Homelessness remains a significant problem among veterans. Among the homeless, mean age at death ranges from 34 to 47 years. Veteran status 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. VA recognizes that care for homeless veterans and for those at the end of life (EOL) are both priorities, but veterans who are both homeless and at EOL do not fit easily into the programs designed for either group.
Objectives: (1) Describe current services for and perceived challenges of caring for homeless Veterans at EOL. (2) Develop a deep and broad understanding of the barriers and facilitators to excellent EOL care for homeless Veterans. (3) Define the key structural, clinical and policy elements required to reach out and deliver excellent care to homeless Veterans at EOL and generate programs that can be tested and replicated across the nation.
Methods: Using mixed methods, we will survey 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 identify 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 two focus groups each: one consisted of multidisciplinary front-line staff and the other of program managers. Chronically ill homeless Veterans and Medical Center leadership were interviewed to understand their perspectives on EOL care for homeless Veterans. We used a broad inductive approach to study rich contextual detail at the individual and group level. A National Program and Policy Development Forum of stakeholders, policy makers, and representatives from each focus group, was convened to draft a white paper addressing the study's policy and system redesign implications.
Findings/Results: An Email Survey of EOL and Homeless Program Points of Contact was completed and published. Programs and care challenge ratings were described statistically. Bivariate analysis and multivariate models compared homelessness and EOL program responses.
Results: Fifty of 152 VAMCs completed the survey. VAMCs treated an average of 6.4 Veterans at EOL annually. Lack of appropriate housing was cited as the most critical challenge.
Conclusions: Personal, clinical and structural challenges face care providers for Veterans who are homeless at EOL.
After developing a deep and broad understanding of the barriers to and facilitators of excellent EOL care for veterans without homes by conducting key informant interviews with community and VA leadership (n=21) and veterans with chronic disease in unstable housing (n=29), and facilitating 10 multidisciplinary focus a National Program and Policy Development Forum was convened to define the key structural, clinical and policy elements required to improve care.
The Forum developed 12 recommendations to address the following barriers: (1) Declining health often makes independent living or plans to abstain impossible, but housing programs usually require functional independence and sobriety. (2) Managing symptoms within the homelessness context is challenging. (3) Discontinuities within and between systems restrict care. (4) VA regulations challenge collaboration with community providers. (5) Veterans with unstable housing who are at EOL and those who care for them must compete nationally for prioritization of their care. The white paper report is in press.
Anticipated Impact on Veterans Healthcare: Care of veterans at EOL without homes may be substantially improved through policy changes to facilitate access to appropriate housing and care; better dissemination of existing policy; cross-discipline and cross-system education; facilitated communication among VA, community, homeless and EOL providers; and pilot testing of VA group homes or palliative care facilities that employ harm reduction strategies.
- Hutt E, Whitfield E, Min SJ, Jones J, Weber M, Albright K, Levy C, O'Toole T. Challenges of Providing End-of-Life Care for Homeless Veterans. The American journal of hospice & palliative care. 2016 May 1; 33(4):381-9.