Hospices Working to Reach Mentally Ill, Homeless

Hospice providers are working to expand resources, services and programs for people who are homeless or experiencing housing insecurity. Homeless seniors are an overlooked and underserved population in the U.S. health care system, including hospice, facing an array of barriers preventing access. The high prevalence of mental illness among the homeless further complicates hospice providers’ efforts to reach them.

Adults 50 and older accounted for nearly half of the nation’s overall homeless population in 2016, a rise from 11% in 1990 largely attributed to an aging baby boomer generation, the National Institute on Aging (NIA) reported. People with a severe mental illness (SMI) accounted for roughly 25% of the chronic homeless population in 2008, according to research from the University of Pennsylvania.

“People experiencing homelessness may not want to engage with hospice services and when they do, they may encounter barriers to accessing palliative and end-of-life care,” said Richard James, public health registrar with Leeds Teaching Hospitals in the United Kingdom. “Hospices are already doing a lot to improve the care provided to people experiencing homelessness with SMIs, predominantly by providing person-centered care that is more tailored to individual needs, [but] a non-tailored hospice approach may not suit people experiencing homelessness. We should not expect service users to be the ones to adapt.”

SMI’s common among the homeless include a range of psychotic disorders such as bipolar disorder, as well as schizophrenia, major depression, along with anxiety, eating and personality disorders that severely impact functional impairment. Additionally, psychotropic medications for these conditions can include greater risk for metabolic adverse effects that impair liver and kidney functions.

This population is also at higher risk of injury. People who are homeless or vulnerably housed are subject to disproportionately high risks of physical and mental illness and are further disadvantaged by difficulties in access to services, according to research published in the BMJ Supportive & Palliative Care Journal.

People with SMI have higher rates of mortality and reduced life expectancy. Leading causes of death reflect those that occur most frequently in the general population such as cardiovascular disease, cancers and respiratory illnesses, according to research from the Journal of Psychopharmacology.

When it comes to reaching homeless populations with SMIs, hospices have room to grow in understanding the underlying issues and tailoring services around their needs, according to James.

“Hospices have a role to play as a part of a wider health and social care system, as providers of care, and as institutions within their communities,” James told Hospice News. “Hospices can reduce inequalities for people experiencing homelessness with SMI by working with partners and patients in tailoring services to meet their needs.”

Many hospices have programs to care for the homeless. These include offering care in hospice houses or at shelters in their communities. These are often nonprofit hospices who use funds from philanthropic donations to finance the programs.

San Diego-based Alpha Project is among the nonprofit organizations with such a program. They launched Hospice for the Homeless in 2007 to provide financial assistance to terminally ill individuals without a home. Through the Living with Dignity Program, Hospice for the Homeless provides one-time financial assistance to help seniors with physical disabilities or other debilitating chronic illnesses. They also provide one-time emergency assistance for rent or a security deposit, transportation, food and mobile devices such as wheelchairs, walkers and blind walking sticks.

Increasing resources for homeless patients with severe or serious mental illnesses requires more community- and home-based services, wherever these individuals dwell, according to Kyla Winters, chief development officer and founder of Hospice for the Homeless program. Locating where home might be for those with SMIs may include laying more ground work within a hospice’s community, Winters indicated.

“Hospice providers should connect with the continuum of care in their counties and communities and find out who are the leading and biggest shelters and homeless centers and facilities. That’s where you’re going to find out where the largest areas of need are,” Winters said. “You need to know how homeless and very low income populations in your area receive health care and work with those places. Providers will then want to ask if they can come onsite often and just let people know about their services and what hospice is about. ”

Hospice providers are seeking to bridge gaps to reach among this underserved, high-needs population by deepening community and professional connections. Hospices have taken leaps in expanding services that address social determinants of health in recent years, including programs aimed at nonmedical needs such as transportation or meals.

An inextricable link rests between the social and structural determinants of health and the homeless population’s care journey, according to Naheed Dosani, M.D., founder and lead palliative care physician for the Palliative Education And Care for the Homeless (PEACH) program. PEACH is a community-based hospice and palliative education and care program for homeless and vulnerably-housed individuals in Toronto, Ontario, Canada.

Providing these supportive nonmedical services can help hospices not only locate areas of high need within their service regions, but also help to form connective relationships with other senior care and mental health organizations. Building stronger community ties can also flow into new referral streams and pathways, according to Dosani.

“It’s about forging those relationships and connecting with people and advocates, whether it’s community-based programs that focus on mental health or primary care, reaching out to the local health facility or even to a hospital that has outpatient mental health care to get a better understanding of how case management is happening,” said Dosani. “Then you build those relationships and you’re able to build and develop referral pathways.”

Having dedicated mental health professionals on their interdisciplinary care teams can be a crucial key for hospices in growing and sustaining connections with homeless individuals. Having a psychiatrist on its outreach program has provided valuable supportive connections and insight, expanding the PEACH program’s ability to address a complex population with serious mental illness through a better understanding of mental health and psychosocial supports needed among homeless individuals, according to Dosani.

“We deal with such significant rates of mental health among the population we serve in Toronto through the PEACH team that we actually have our own in-house outreach psychiatrist, and that’s been a very crucial connection for us,” Dosani told Hospice News. “We are embedded within the home and community care health care system, which allows us to connect with a whole host of professionals. We are able to work with our mental health colleagues, particularly community-based mental health workers, case management and mental health professionals who do outreach to provide concordant care and parallels to palliative care.”

Roughly 1 in 25, or 10.4 million, adults nationwide have an SMI, reported the American Psychiatric Association. Of these, 65% receive “effective psychopharmacological and psychosocial treatments that support improved functioning and quality of life,” according to the Association.

Barriers to health care at the end of life among homeless individuals with SMIs include unstable living and housing conditions, a lack of social or family support, limited access and ability to afford psychiatric medications, a fear of discrimination and distrust in medical professionals, and cognitive or communication impairments that prevent acknowledgement or awareness of the significance of their health conditions, among others.

Requiring sensitivity training and education around homelessness among staff will be a vital key for reaching those with SMIs, according to Winters.

“Different types of training are helpful for hospice providers to have for their staff members, including trauma-informed care,” said Winters. “It’s really to have a good understanding of the trauma that these patients have often endured at points in their life or are continuing to go through at the end of life. You need to meet them where they’re at — not to try to change them. You can encourage and help them, but there is a fine line between encouraging and trying to change someone’s lifestyle when they’re facing their end of life. Staff need to understand how to give that dignity and respect in unique homeless situations.”