Oscillating in and out of place: Experiences of older adults residing in homeless shelters in Montreal, Quebec

"I Feel Like a Somebody Again": Ethics of Care at a Shelter for Older Adults Fleeing Abuse in Canada

Abuse against older adults is an under-researched pathway to older adult homelessness. This paper fills a gap through a secondary data analysis of qualitative interviews with five providers and 10 clients from a homeless shelter serving older adults fleeing abuse. Drawing on a feminist ethics of care framework, we explored the role of care in participants' experiences of shelter life and what aging in the right place meant to them, identifying three themes: 1) cultivating trust and relationship-building between providers and clients; 2) caregiving, mutual care, and collective care among clients; and 3) lack of care and processes of repair.

Social inequity in ageing in place among older adults in Organisation for Economic Cooperation and Development countries: a mixed studies systematic review

BACKGROUND

Most older adults wish to remain in their homes and communities as they age. Despite this widespread preference, disparities in health outcomes and access to healthcare and social support may create inequities in the ability to age in place. Our objectives were to synthesise evidence of social inequity in ageing in place among older adults using an intersectional lens and to evaluate the methods used to define and measure inequities.

METHODS

We conducted a mixed studies systematic review. We searched MEDLINE, EMBASE, PsycINFO, CINAHL and AgeLine for quantitative or qualitative literature that examined social inequities in ageing in place among adults aged 65 and older in Organisation for Economic Co-operation and Development (OECD) member countries. Results of included studies were synthesised using qualitative content analysis guided by the PROGRESS-Plus framework.

RESULTS

Of 4874 identified records, 55 studies were included. Rural residents, racial/ethnic minorities, immigrants and those with higher socioeconomic position and greater social resources are more likely to age in place. Women and those with higher educational attainment appear less likely to age in place. The influence of socioeconomic position, education and social resources differs by gender and race/ethnicity, indicating intersectional effects across social dimensions.

CONCLUSIONS

Social dimensions influence the ability to age in place in OECD settings, likely due to health inequalities across the lifespan, disparities in access to healthcare and support services, and different preferences regarding ageing in place. Our results can inform the development of policies and programmes to equitably support ageing in place in diverse populations.

Countering social exclusion through inclusive homecare provision: Utilising a participatory life-course approach to influence policy

Homecare models can be effective mechanisms in securing wellbeing and ageing-in-place goals prevalent in health policy agendas. However, the relevance and utility of these models for those living in socially and environmentally insecure conditions has rarely been considered. This is marked by an assumption of in-situ care delivery in private dwellings, and the absence of such groups from homecare development processes. This study aims to harnesses the experiences and preferences of older people in homelessness (OH), older Irish Travellers (OT), and professional stakeholders in an evidence-based co-production of policy recommendations for inclusive homecare provision. The study employed a participatory approach involving the integration of lived experience evidence in a multistakeholder co-production process. Methods comprised: five separate focus groups with OH, OT and service providers (n = 30); two consultative forums involving focus group participants together; and 49 life-course interviews with OH (n = 27) and OT (n = 22) and adults. Findings demonstrate that sizeable gaps in care remain for these groups, and that resource constraints and legislative restrictions prevail for professional stakeholders. Co-produced policy recommendations for inclusive homecare provision based on these experiences and group preferences are presented and discussed.

Canadian Health Care Providers' Perspectives on Working with Older Homeless Adults in Outreach Settings

Service providers have a unique understanding of older homeless adults' challenges and service needs. However, research on the experiences of health care providers (HCPs) who work with this population is limited. We aimed to gain a better understanding of the experiences (roles, challenges, and rewards) of HCPs who work with older homeless adults (age 50 and over) in outreach settings. We conducted individual semi-structured interviews with 10 HCPs who worked in these roles. Four themes emerged: (a) the client-provider relationship as an essential building block to HCPs' work; (b) progression of care that acknowledges the "whole person"; (c) collaboration as integral to providers' work; and (d) the importance of system navigation. Providers found their work personally and professionally fulfilling but were frustrated by system-level challenges. Findings can be used to identify strategies on how to further support providers in their roles and enhance service provision for older homeless individuals.

Pathways of Individuals Experiencing Serious Illness While Homeless: An Exploratory 4-Point Typology from the RASCAL-UP Study

The shifting age demographics of those experiencing homelessness in the United States expose shortcomings and barriers within homelessness response services and safety-net healthcare to address serious illness. The purpose of this study is to describe the common trajectories of patients concurrently experiencing homelessness and serious illness. As a part of the Research, Action, and Supportive Care at Later-life for Unhoused People (RASCAL-UP) study, the study uses patient charts (n = 75) from the only specialty palliative care program in the U.S. specifically for people experiencing homelessness. Through a thematic mixed-method analysis, a four-point typology of care pathways taken by people experiencing homelessness while seriously ill is introduced: (1) aging and dying-in-place within the housing care system; (2) frequent transitions during serious illness; (3) healthcare institutions as housing; and (4) housing as palliation. Implications of this exploratory typology include targeted, site-specific interventions for supporting goal-concordant patient care and assisting researchers and policy makers in appreciating heterogeneity in experience and need among older and chronically ill people experiencing homelessness and housing precarity.

Delivering Services to Older Persons Experiencing Homelessness: Providers' Perspectives of What Does and Does Not Work

Older people with experiences of homelessness (OPEH) tend to experience more complex health, social, and psychological issues than people experiencing homelessness at younger ages. Simultaneously, many housing resources (e.g., shelters, temporary housing) are often ill equipped to meet the needs of OPEH. As such, OPEH are often unable to age in the right place (AIRP) - that is, in a place that supports unique needs and vulnerabilities. However, several promising practices exist that deliver housing and services tailored to OPEH. To investigate the aspects of housing and shelter that both promote and impede AIRP for OPEH, this study examines the delivery of services in three such promising practices from the perspective of service providers. Findings from fifteen qualitative interviews revealed three overarching themes: 1) barriers to providing individualized support (e.g., staff turnover); 2) shifting contexts and structures (e.g., housing market changes); and 3) mechanisms of success (e.g., facilitating smooth transitions into permanent housing). These findings provide evidence to support the refinement of service delivery to promote AIRP for OPEH. In doing so, these insights can help to elevate promising practices to the level of best practice.

Understanding the Ephemeral Moment of COVID Avoidance Hotels: Lessons Learned from Acknowledging Housing as Central to Dignified Later Life

Place and health are intricately bound. COVID has amplified system burdens and health risks within the housing care continuum, in which older adults with chronic illnesses are disproportionately represented. The paper identifies the health experiences of older adults with severe conditions living in and moving through temporary avoidance hotels during the COVID-19 pandemic. An interpretive descriptive approach was taken with qualitative chart data and provider observation to represent the experiences of 14 older avoidance hotel residents living with serious illnesses. Through provider documentation, we illustrate trends pre-pandemic, in the first nine months of the pandemic, and the second nine months. Such trends include strengths and opportunities such as the health-affirming nature of avoidance hotels, their potential in generating continuity of care and permanent housing, and synergy between harm reduction approaches and palliative care. Challenges were also identified in catering to the diverse medical, behavioral, and psychosocial-spiritual needs of older and seriously ill residents and the consequences of geographic dispersion on health care, health behaviors, and informal care networks. Through these strengths and challenges, avoidance hotels present essential lessons in considering future housing and healthcare intervention and implementation that addresses the needs of older seriously ill people facing homelessness and housing precarity.

"A right place for everybody": Supporting aging in the right place for older people experiencing homelessness

While policies and practices that promote aging in place have risen in prominence over the last two decades, marginalised older adults have largely been overlooked. 'Aging in the right place' is a concept that recognises the importance of adequate and appropriate age-related health and psychosocial supports in shelter/housing settings and their impact on the ability of older people to age optimally. To understand the unique shelter/housing challenges and solutions that affect aging in the right place for older people experiencing homelessness (OPEH), we conducted three World Café workshops in three Canadian cities-Montreal, Calgary, and Vancouver. In total, 89 service providers and OPEH engaged in the workshops, which involved guided, small-table discussions with the goal of stimulating creative ideas and fostering a productive atmosphere. Findings revealed two overarching themes 1) Discrepancies, between the need and availability of housing options and community supports for OPEH, such as affordable transportation, case management, access to healthcare, and system navigation; and 2) Desires, for more peer support, participatory planning, service-enriched housing, social programming, and policies that promote agency, independence, and choice for OPEH. These findings provide evidence to inform the development or modification of housing and supports for OPEH that promote aging in the right place.

Ageing in place processes in the neighbourhood environment: a proposed conceptual framework from a capability approach

The concept of "ageing in place" has become increasingly significant in the environmental gerontology literature. Despite its predominance, there have been limited efforts to offer a more comprehensive and nuanced conceptualization of this topic. Definitions found in the literature are often too simplistic and only partially capture the various aspects of older adults' experience while ageing in place. This paper presents a conceptual framework on ageing in place in the context of neighbourhood environment which aims to address this gap by proposing a multi-faceted understanding of ageing in place processes through the lenses of a capability approach, a more comprehensive definition of the concept, and related overarching principles. Building on predominant theories in environmental gerontology, this conceptual framework offers new insights into the interactions between "place" and the "ageing individual". It is meant to offer opportunities for discussion, to suggest new paths of inquiry, and to explore implications for policy and practice.

Aging in the downtown corridor: Mapping the neighborhood experiences of Seattle's unhoused adults over age 50

Research has established the importance of understanding the dynamic relationship between older adults and the environments in which they are embedded. However, the meaning of place for unhoused older adults amidst an increasingly contested urban landscape is largely unknown. This exploratory study aims to further include unhoused older adults' experiences in the scholarship on aging and place by asking how unhoused adults over age 50 (1) describe their spatial patterns and experiences and (2) negotiate their relationship with common urban places. Through iterative mapping conducted in focus groups and interviews at Seattle senior centers, respondents identified how they interacted with their communities and environment. Using inductive and deductive coding of both textual and geospatial data, thematic analysis indicated that respondents: (1) experienced confinement to the downtown corridor and expulsion from surrounding areas- a phenomenon compounded by physical and subjective aging; (2) created routines amidst geographic and temporal restrictions to maximize comfort and security; (3) attempted to create residential normalcy in public places through adaptive and accommodative practices; and (4) experienced identities shaped by movement through and access to place. Current social, spatial, and political contexts of city living present many challenges for older unhoused adults. Supports that ignore people's identification with the places that are important to them are unlikely to be successful. Findings from this paper call for service, policy, and design strategies that facilitate personal agency and connection to place among unhoused people midlife and beyond.

Aging in Place Among Older Adults With Histories of Traumatic Experiences: A Scoping Review

BACKGROUND AND OBJECTIVES

Adverse childhood and adult experiences can have far-reaching impacts and, when coupled with typical aging-related changes, may impede the achievement of a suitable person-environment fit for aging adults. The objective of our study was to determine whether extant literature connects older adults with trauma history to successfully aging in place.

RESEARCH DESIGN AND METHODS

We proposed a conceptual model regarding trauma history, adaptive capacity of aging adults, and trauma-informed supports for aging in place. We conducted a scoping review using 6 databases (keywords: older adult(s), aging in place, housing, trauma), with a full review of 32 articles.

RESULTS

Insights included: (a) Aging in place does not have to mean living in the same house over time. (b) The uncertainty of the aging process can be traumatic and can be exacerbated by previous traumatic experiences. (c) Environmental sensitivities can result from previous traumatic experiences and cause further trauma. (d) Housing precarity is a traumatic experience. (e) Permanent supportive housing is an important resource for people in crisis. (f) Community supports are critical to aging in place.

DISCUSSION AND IMPLICATIONS

Our review revealed insights about aging in place and trauma, but did not connect the vulnerabilities specific to aging adults with personal trauma histories to aging in place. Research is needed that confirms the relationship between history of traumatic experiences and difficulties with aging in place as well as trauma-informed approaches that can mitigate housing-related stressors and foster community-living environments that provide equitable access to aging in place.

Bridging the Gap between Homelessness in Older Adulthood and Elder Abuse: Considerations for an Age-Friendly Shelter System

Homelessness and elder abuse are two major public health issues affecting older adults that are increasing in scope due to global population aging. While these issues have typically been examined separately, this commentary considers the often overlooked intersection between homeless older people and victims of elder abuse through two pathways: (1) the systemic abuse of older adults in the shelter system; and (2) the role of elder abuse as a possible risk factor for homelessness in later life. Strategies for the development of shelter systems that support the diverse needs of an aging population are proposed.

Shelter/housing options, supports and interventions for older people experiencing homelessness

While experiences of later-life homelessness are known to vary, classification of shelter, housing and service models that meet the diverse needs of older people with experiences of homelessness (OPEH) are limited. To address this gap, a scoping review was conducted of shelter/housing options, supports and interventions for OPEH. Fourteen databases were searched for English-language peer-reviewed and/or empirical literature published between 1999 and 2019, resulting in the inclusion of 22 sources. Through a collaborative, iterative process of reading, discussing and coding, data extracted from the studies were organised into six models: (1) long-term care, (2) permanent supportive housing (PSH), including PSH delivered through Housing First, (3) supported housing, (4) transitional housing, (5) emergency shelter settings with health and social supports, and (6) case management and outreach. Programme descriptions and OPEH outcomes are described and contribute to our understanding that multiple shelter/housing options are needed to support diverse OPEH. The categorised models are considered alongside existing ‘ageing in place’ research, which largely focuses on older adults who are housed. Through extending discussions of ageing in the ‘right’ place to diverse OPEH, additional considerations are offered. Future research should explore distinct sub-populations of OPEH and how individual-level supports for ageing in place must attend to mezzo- and macro-level systems and policies.

Later-Life Homelessness as Disenfranchised Grief

ABSTRACTAlthough interest on older homelessness is gaining momentum, little research has considered the experiences of first-time homelessness from the perspective of older adults themselves. This constructivist grounded-theory study addresses this gap by exploring how societal perceptions of homelessness and aging shape access to housing, services, and perceptions of self for 15 older adults residing in emergency homeless shelters in Montreal, (Quebec, Canada). Findings revealed that homelessness evoked a grief response characterized by shock, despair, anger, and in some cases, relief. Connecting and receiving support from other shelter residents and staff helped participants to acknowledge and grieve their losses. However, difficult shelter conditions, the stigma associated with aging and homelessness, and not having their grief recognized or validated served to disenfranchise grief experiences. Conceptualizing later-life homelessness as disenfranchised grief contributes to the aging and homelessness literature while providing new avenues for understanding and validating the experiences of a growing population of vulnerable older adults.