Hospices are increasingly collaborating with community organizations to better address the end-of-life needs of the homeless population. 

Isolated homeless senior populations are reaching concerning levels nationwide. Many medical and nonmedical issues can be exacerbated at the end of life among unhoused and homeless seniors compared to others, according to James Patrick Hall, executive director of Rocky Mountain Refuge. The Denver-based nonprofit organization offers shelter for people with end-of-life care needs.

“It’s traumatizing to be living on the streets in general, and the conditions they live in are traumatizing,” Hall told Hospice News. “We as a nation should be concerned about where people are experiencing homelessness, because they die where they live — and that’s a powerful statement that’s becoming a bigger and bigger problem.”

A growing need for care

Rocky Mountain Refuge provides shelter for unhoused individuals approaching the end of life as well as a continuum of care. Services include personal care, assistance with daily activities of life, nonmedical and caregiving support, and pain, symptom and medication management. Individuals can receive clinical care visits one or twice weekly, depending on hospice organizations’ staffing availability and care needs.

Unaddressed issues with addiction and untreated mental and physical health conditions have some homeless individuals facing the end of life far sooner than others – and with greater challenges, he continued. Some homeless individuals approaching the end of life may be decades younger than the average hospice patient.

Care delivery should account for their potentially vastly different physical abilities and goals-of-care compared to seniors. They may also need access to a continuum of care further upstream of hospice, he stated.

Homeless populations have increased across the country in recent years, with seniors among those reaching “record-high” volumes and outpacing other demographic groups, Harvard University’s Joint Center for Housing Studies research recently reported. Recent significant factors include economic hardships, pandemic-related impacts and rising housing costs, the research found.

Individuals 55 and older represented nearly one-third (29.0%) of all people experiencing homelessness nationwide in 2023, according to an annual report from the U.S. Department of Housing and Urban Development (HUD). Projected to swell during the next decade, this age cohort made up 31.7% of sheltered individuals and 26.2% of unsheltered persons that year, the HUD report found.

The data illustrate a swelling homeless population with unmet end-of-life care needs who are suffering and dying alone, said Michaela Chase, assistant vice president of access at the Wisconsin-based hospice and palliative care provider Agrace.

Homeless populations are at greater risk of having significant practical, physical and emotional challenges at the end of life, according to Chase. Homeless seniors are more likely to have multiple comorbidities, higher acuity needs and lack caregiving support compared to others, she stated.

“People who are experiencing homelessness may more easily be victimized because they are so vulnerable,” Chase told Hospice News in an email. “They often lack consistent health care, leading to delayed diagnoses, untreated chronic conditions and a higher likelihood of end-stage diseases. They often find themselves without caregivers or support people, contributing to additional challenges for someone at the end of their life.”

Health care costs are climbing as these individuals most commonly utilize emergency and urgent care at the end of life, since they will not be turned away due to a lack of affordability or insurance coverage, Chase said.

This trend has a trifecta effect: increased health care spending, taxing a shrinking clinical workforce plagued by shortages and posing negative quality experiences among patients, she stated.

Hospice providers are an important cog in the systematic wheel toward improving quality and cost, Chase indicated. Health care providers and community organizations need stronger collaborations to better support homeless populations at the end of life, she said.

“Coordinating care between health care providers, social services and other community partners can ensure comprehensive support,” Chase said. “In addition to helping avoid costly unnecessary ER visits, hospice care can help manage pain and symptoms, providing better comfort and quality of life.”

Homeless hospice care models taking shape

Agrace is among the hospice and palliative care providers collaborating with Solace Friends Inc., which recently launched an adult family center for terminally ill individuals in unstable or insecure housing situations.

Individuals who elect to receive hospice at the Solace House facility will receive care from local providers such as Agrace, Heartland Hospice, Interim HealthCare of Madison and SSM Health at Home-Wisconsin.

A main goal of establishing the facility is to provide a safe and comfortable environment for those approaching the end of life.

The community collaboration has helped to increase awareness and understanding of the interdisciplinary care and practical resources available to homeless individuals across various Wisconsin regions, Chase said. It has also taken “getting creative” in how they work together to form an “arsenal of resources,” such as inpatient hospice care and residential support, she added.

Goal-concordant, person-centered care for homeless populations takes a very different interdisciplinary approach that accounts for the largest hurdle – a lack of stable shelter and place to provide it, said Shinae Reynolds, regional administrator of hospice operations at Interim Hospice and Palliative Care.

The Interim HealthCare franchise serves Green Bay, Wausau, Eau Claire and Hudson, Wisconsin, along with Rochester, Minnesota. Interim HealthCare Inc. is part of the Great Lakes Health Partners system.

“The most important thing is finding out what is most important to every patient, and it’s likely going to look very different in this [homeless] population than it does for someone else,” Reynolds told Hospice News. “They still deserve the same level of care we’re providing to anyone else and it’s about really being able to provide individualized care.”

A lack of trust in the health care system represents one of the most significant barriers to improved quality and access among homeless populations, Reynolds said. Serious and terminally ill homeless seniors may experience higher rates of bias, stereotypes and even mistreatment among health care providers that can negatively impact their outcomes in several ways, she explained.

Community collaborations can help foster trust among homeless seniors who could benefit from end-of-life services, Reynolds stated.

“They feel that they’re not always taken seriously, which causes them to seek treatment or care much later in those disease processes,” she said. “Addressing those challenges for them takes time to build trust [and] make sure they feel comfortable with the team. It’s not going to happen overnight. It’s pulling in the interdisciplinary team with clinical, spiritual and social worker resources, housing programs and different financial programs that they maybe never were even aware of before to really get on the level of the challenges they face at the end of life.”

Having more hospice and homeless shelter collaborations could help address some of the systemic challenges tied to these health disparities, Hall said.

Support and shelter are among the two significant quality pieces for homeless individuals, Hall said. With these comes a safe place to store and take medications under medical professional guidance and without fear of becoming a target for theft, robbery or abuse on the streets, he added.

Having sustainable support can potentially help prevent end-of-life medications from being lost, illegally sold and lowers the risk of an overdose, Hall explained.

“It’s about having some control over their end-of-life and [having] a place for them to be able to meet hospice clinicians, chaplains or social workers that’s safer for everyone,” Hall said. “If they have a place to take care of themselves that makes them more comfortable and it isn’t just doing their medical care. That’s the social model hospice house approach – they’re not stressed by being afraid of dying alone all the time.”