"I Don't Want to Die on the Street": Patient and Practitioner Perspectives on Street-Based Care for Older Adults Experiencing Unsheltered Homelessness

BACKGROUND

Unsheltered older adults experiencing homelessness constitute the fastest-growing segment of the US unhoused population. Research shows that older unsheltered adults have more chronic health conditions and experience accelerated aging. Little is known about the unique considerations in providing care and support for this population.

OBJECTIVE

To explore the experiences of aging and managing serious illness from people experiencing unsheltered homelessness and from the street medicine team members who care for them.

DESIGN

Qualitative, semi-structured in-depth individual interviews.

PARTICIPANTS

Street medicine team members and patients receiving street medicine in Los Angeles.

APPROACH

Interviews were guided by a semi-structured interview guide developed by the team, audio-recorded, and transcribed verbatim. Field notes supplemented transcripts. Transcripts and field notes were analyzed by two independent coders following a thematic analysis approach rooted in grounded theory.

KEY RESULTS

Eight street medicine team members with varying experience caring for patients experiencing homelessness (1-16 years) and from multidisciplinary backgrounds were interviewed. Team members were, on average, 39 years old (SD 7.4 years), 63% female, and 50% white. Eight patients were interviewed and identified as male (63%), having 3 + chronic health conditions (100%), and aged on average 56 years (range 50-71; SD 4.7 years). Thematic analysis of the interviews revealed two major themes on challenges and considerations for the following: (1) Caring for older adults experiencing unsheltered homelessness (subthemes: Medical, Interpersonal, Environmental, and Systemic), and (2) Shelter, long-term care, and end-of-life planning among older adults experiencing unsheltered homelessness (subthemes: Permanent shelter, Rehabilitative and institutional care, and End-of-life care planning).

CONCLUSIONS

Team member and patient perspectives offered insight into significant challenges faced when trying to apply conventional healthcare practices to the unique circumstances of the unsheltered setting. Findings suggest actionable strategies with implications for both policy and practice to better meet the needs of unsheltered homeless older adults.

Mechanisms to Promote Social Integration in a Temporary Housing Program for Older Persons Experiencing and At-Risk of Homelessness

BACKGROUND AND OBJECTIVES

Social integration-the degree to which a person is socially connected and engaged with other people-is a programmatic goal of supportive housing models and a predictor of successful housing outcomes among clients. Although research has examined social integration within permanent supportive housing models, minimal research has considered how social integration may be promoted within temporary housing programs (THPs), particularly for older persons. This study examines experiences of social integration, connection, and participation within a scattered-site THP for older persons experiencing homelessness in Vancouver, Canada.

RESEARCH DESIGN AND METHODS

We conducted semistructured qualitative interviews with 11 current and former clients. Data were analyzed using a critical realist-informed thematic analysis method wherein theme development attempts to link events (e.g., accessing a service) and experiences (e.g., feeling supported).

RESULTS

We identified 3 mechanisms: (a) technology access facilitates connection to individuals and organizations; (b) frequent communication with staff enhances feelings of social support and reduces isolation; and (c) accessible environments promote social connection and participation.

DISCUSSION AND IMPLICATIONS

Findings offer novel insights into promoting social integration in THPs, such as creating "third places," and suggestions for supporting older persons transitioning out of homelessness.

A Systems Approach to Homelessness Prevention for Older Adults

An aging population and increase in the number of older adults experiencing homelessness in North America requires a more effective response to prevent and end older adult homelessness. While there are few research evidence-based policy solutions to preventing older adult homelessness, there are several promising practices that with further analysis could point to quality policy reform. Using the five-level typology by Fitzpatrick et al. (2021. Advancing a five-level typology of homelessness prevention. International Journal on Homelessness, 1(1), 79-97. doi:10.5206/ijoh.2021.1.13341), this discussion paper outlines policy-oriented recommendations at varying levels of prevention: (a) universal, (b) upstream, (c) crisis, (d) emergency, and (e) repeat. Key policy implications include intersectoral collaboration and policy design that seeks to successfully reach functionally zero homelessness by activating policy strategies at each of the five-levels of prevention. Health and housing practitioners play an essential role in policy planning, design, implementation, and evaluation and can participate in and advocate for opportunities to improve services and address older adult homelessness connected to their practice environments. Promoting research that enhances systematic evaluation of the outcomes of older adults through various housing models is critical to driving policy reform-a necessary action to promote a safe, healthy, and opportunistic future for older adults.

Increasing Social Connection in Permanent Supportive Housing: A Participatory Study on Therapeutic Recreation for People With Experiences of Homelessness

BACKGROUND AND OBJECTIVES

Social exclusion and isolation due to homelessness are compounded in older people by physical frailty and stigma. Interventions to support older people with experiences of homelessness often neglect social dimensions of well-being. In this participatory action research study, residents, staff, and researchers collaborated to develop, implement, and evaluate therapeutic recreation programming in a permanent supportive housing facility for older people with experiences of homelessness (n = 68).

RESEARCH DESIGN AND METHODS

A community advisory group, "The Exchange," co-designed program delivery and evaluation. Quantitative evaluation data consisted of participant demographics, participation rates, goals set, and quality of life questionnaires at three points in the study. Qualitative data included co-design meeting notes (n = 24), and interviews with residents (n = 19) and staff (n = 20). Quantitative data were reported descriptively, and qualitative data were analyzed thematically, using social and ecological theories of care from recreation studies as a sensitizing lens. Data were synthesized to develop a final interpretation.

RESULTS

Sixty-one (90%) residents participated in recreation programming. Residents set 253 goals; social goals were the most popular. Residents reported increased confidence to learn new skills, engaging in meaningful activities, and improved social connection with their community.

DISCUSSION AND IMPLICATIONS

Co-designing recreation programming contributed to an inclusive social environment that enhanced individual and community connectivity. The findings demonstrate the benefits of therapeutic recreation in promoting well-being among older people with experiences of homelessness living in permanent supportive housing.

Experiences of Trauma for Older Adults With Lived and Living Experiences of Homelessness in Middle to High Income Countries: A Systematic Review and Meta-Aggregation

BACKGROUND AND OBJECTIVES

Research has identified that the number of older adults experiencing homelessness in middle to high income countries is growing. Coincidingly, in recognition that individuals with housing precarity often have experiences of trauma, there have been increasing calls for trauma-and-violence-informed care (TVIC) in practice and research. We conducted this review to consolidate existing literature that explores experiences of trauma among older adults who have experienced homelessness.

RESEARCH DESIGN AND METHODS

We conducted a systematic review of qualitative evidence and meta-aggregation following the Joanna Briggs Institute methodology, in adherence with PRISMA guidelines.

RESULTS

Our search yielded 24 studies. Through a process of meta-aggregation, we generated 5 synthesized findings: (a) Being let down by society and systems; (b) the world is not a safe place; (c) survivor not victim; (d) living in the long shadow of trauma; and (e) homelessness as a deeply personal trauma.

DISCUSSION AND IMPLICATIONS

Our findings underscore the reality that older adults without housing face multiple experiences of trauma, including the trauma of homelessness itself. Considering these findings, research, practice, and policies need to focus on ways to better support older adults, both in preventing trauma and assisting those who have already experienced trauma. Our findings indicate the necessity of: (a) implementing TVIC across all sectors who work with older adults; (b) supporting older adults to age in place in safe, deeply affordable, accessible housing; and (c) creating shelter environments more suitable for older adults, and especially those who have experienced trauma.

"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.

Intersections of Ageism and Homelessness Among Older Adults: Implications for Policy, Practice, and Research

Ageism remains a key issue in gerontological literature and has long been recognized as a deeply harmful form of discrimination. Despite advances in ageism scholarship related to education, advocacy, and prevention, there are calls for ongoing intersectional examinations of ageism among minority groups and across older people facing multiple exclusions. In particular, very little ageism research has considered the experiences of age-based discrimination and prejudice among older people experiencing homelessness. We problematize this gap in knowledge and provide recommendations for policy, practice, and research to address ageist discrimination toward older people experiencing homelessness. Intersections of ageism and homelessness are summarized at four levels: intrapersonal, interpersonal, institutional/community, and societal/structural. Building upon the limited research, we recommend key strategies for supporting and protecting older people experiencing homelessness through the reduction of ageism at each level. We present these insights and recommendations as a call to action for those working in both the aging and housing/homelessness spheres.

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.

"Whatever journey you want to take, I'll support you through": a mixed methods evaluation of a peer worker program in the hospital emergency department

BACKGROUND

People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer.

METHODS

Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients (n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers (n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data.

RESULTS

Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department.

CONCLUSIONS

The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.

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.

"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.

"I Have Failed Them and Failed My Duties": Experiences of Hospital Social Workers Discharging Patients into Homelessness

Homelessness is a long-standing issue at the forefront of healthcare globally, and discharge of homeless patients from hospital settings can exacerbate gaps and burdens in healthcare systems. In hospitals, social workers often take on the majority of responsibility for facilitating patient discharge transitions out of hospital care. Research in this area to date has explored experiences and outcomes of homeless clients, and the experiences of social workers in these roles are not well known. The current study's objective was to elucidate observations and experiences of hospital social workers who discharge patients into homelessness. A total of 112 social workers responded to an online questionnaire, and responses to open-ended questions were analyzed for thematic content. Four overarching themes emerged: (1) complexity of clients, (2) systemic barriers, (3) resource gaps, and (4) negative impact on social workers. It is clear that significant change is required to address the multitude of challenges that intersect to reinforce health inequities. Results can be used by social workers, health authorities, community providers, researchers, and policymakers in discussions about best practices for homeless clients.

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.

Creating structural community cohesion: Addressing racial equity in older adult homelessness

Older adults and racial minorities are overrepresented in homeless populations. Shelter and housing options for homeless older adults who have complex health and social needs are necessary, but not readily available. Older homeless adults that require, but do not receive, health-sensitive, age-sensitive, and racial equity housing, remain vulnerable to poor outcomes and premature mortality. Accordingly, this study examines the development of a coalition to better address older adult homelessness within a racial equity framework. A community coalition was established to better address older adult homelessness within the lens of age-sensitivity and racial equity, due to a disconnect between healthcare and senior housing placement programs, creating unaddressed multifaceted health issues/complications. The community coalition development is described, including the coalition process, activities, and outcomes. Local rehoused older adults are also interviewed and described to better understand their central life circumstances.

Factors Associated with Free Hospital Outpatient Service Use among Middle-Aged and Older Urban Homeless Adults in Taipei

Homeless individuals have many negative experiences with inequality regarding access to and the use of primary healthcare services, so policies to eliminate the disparities in and barriers to primary care access for these people are needed. The aim of this study was to explore the use and determinants of free hospital outpatient services for homeless people, in order to describe the provision of free healthcare policies for this vulnerable population in Taipei. One cross-sectional survey was conducted to recruit homeless people aged 45 years old and over in Taipei in 2018. A structured questionnaire was used, and face-to-face interviews were conducted by three social workers to collect the data. Finally, 129 participants were recruited in the study. The results show that 81.4% of the homeless people had made free hospital outpatient care visits (mean = 5.9 visits) in the last three months. An unadjusted logistic regression analysis showed that those homeless people who reported having usual healthcare providers, with higher depressive symptom scores, who used medication and had been hospitalized within one year, and had more chronic diseases, were significantly more likely to make free hospital outpatient visits. The adjusted logistic regression model indicates that homeless people with severe depressive symptoms (odds ratio (OR) = 9.32, 95% CI = 1.15–56.07), who had received medication (OR = 3.93; 95% CI = 1.06–14.52), and who had more than five chronic diseases (OR = 1.06, 95% CI = 1.35–13.27), were significantly more likely to make free hospital outpatient visits than their counterparts. The findings highlight that homeless people have higher healthcare requirements than the general population, and the healthcare system should pay more attention to factors associated with higher outpatient service use, such as homelessness, severe depressive symptoms, the receipt of medication and chronic diseases.

The Efficacy of the Geriatric Model of Care in Emergency Housing Programs for Homeless Veterans

INTRODUCTION

The aging homeless population currently makes up half the general homeless population. However, there are few homeless emergency shelters that can address their needs. This results in an overutilization of inpatient admissions and emergency room services.

METHODS

Homeless service staff from VA Palo Alto Health Care System partnered with a local homeless emergency housing provider, Compassion Residio Services Inc., to implement this new model of care for aging, medically fragile homeless Veterans. This emergency housing model utilizes practices done in geriatric settings. This model aimed to help decrease the utilization of emergency departments and inpatient admissions.

RESULTS

The average cost of emergency department visits and inpatient admissions was $127,314 per Veteran 6 months before admission. Six months after discharge, the average cost of treatment from emergency department visits and inpatient admissions was roughly $59,546 after discharge, a 53% decrease. Emergency department visits decreased from an average of 5.6 visits per Veteran 6 months before admission to 2.65 visits after 6 months discharge. The number of inpatient nights decreased from an average of 15 days per admission in the 6 months before the program to 13 days. Total admissions decreased by nearly half from 48 the previous 6 months to 25 after 6 months.

DISCUSSION

Overall, as residents settled into stable environments tailored around geriatric care, the utilization of emergency department visits and inpatient services decreased. Furthermore, the complexity (eg, cost per encounter) also decreased.

Design Considerations for the Development and Implementation of a Medical Respite for Older Adults Experiencing Homelessness in Metro Vancouver

BACKGROUND

Older persons with lived or living experience of homelessness (PWLEs) often live with complex physical and/or mental health conditions which are challenged by poor access to health services, especially primary care. To fill the gap in the continuum of care following hospital discharge for PWLEs, medical respite provides health and shelter support for PWLEs who do not have acute care needs that qualify for a stay in a hospital bed, yet are too sick or frail to recover on the streets or in a traditional shelter.

OBJECTIVE

This study examines how a medical respite could be designed for older PWLEs in Metro Vancouver, BC.

RESEARCH DESIGN

Using a community-based participatory research approach, in-depth interviews and focus groups were conducted with PWLE (n=15) and service provider (n=11) participants.

RESULTS

Participants offered rich suggestions about (a) the culture of the medical respite, (b) the physical design of a medical respite, (c) individuals who should be involved in medical respite delivery, (d) services a medical respite should provide, and (e) who the medical respite should serve.

CONCLUSIONS

When designing a medical respite for older PWLEs, considerations include providing an environment where patients can rest, but also feel safe and be surrounded by persons who they trust and who care for them. Developing a medical respite that adheres to the tenets of trauma-informed and patient-centered care acknowledges the mistrust and traumatization that often accompanies homeless patients presenting to health care.

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.

Air Pollution-Related Health Impacts on Individuals Experiencing Homelessness: Environmental Justice and Health Vulnerability in Salt Lake County, Utah

Experiences of homelessness, although widely varied, are characterized by extensive time in public spaces, often outdoors. However, there has been little empirical research about the ways in which environmental factors affect individuals experiencing homelessness (IEHs). Therefore, the purpose of this study was to use an environmental justice approach to understand how cardiopulmonary health of IEHs is affected by episodic poor air quality in Salt Lake County. It was hypothesized that people who had experienced unsheltered homelessness and those who had been experiencing homelessness for longer periods of time would report greater health difficulties from poor air quality exposure. Through a combination of in-person semistructured interviews with IEHs (n = 138) and access to corresponding state-based service provider databases, researchers examined both overall descriptives of and relationships between types (sheltered and unsheltered) and duration (chronic and nonchronic) of homelessness. More than 61% of IEHs reported physical reactions to air pollution, 37% reported air pollution-related emotional stress, and more than 89% had sought medical attention for a condition related to air pollution. Findings indicate that while IEHs report a number of health effects related to poor air quality, there were no significant differences between individuals based on either sheltered status or duration of their experiences of homelessness. This study provides an initial empirical inquiry to understand how environmental disamenities negatively influence IEHs, as well as noting that sheltered status and duration of homelessness are less impactful than originally hypothesized.

Positive health among older Traveller and older homeless adults: A scoping review of life-course and structural determinants

Concepts related to positive health in later life are increasingly prevalent within community-based health and social care policy. With a greater emphasis on inclusion health for older populations, there is a critical need to understand the determinants of such states for those most at risk of societal disadvantage. Focusing on two such groups, the aim of this article is to synthesise international research on the life-course and structural determinants of positive subjective health for older homeless people and older Irish Travellers. Two scoping reviews were conducted (one for each group) to capture state-of-the art knowledge published from 1998 to 2020. The reviews were completed from July to December 2018, and repeated from March to April 2020. Thirty-eight publications were included in the final sample (older Travellers: 10 sources; older homeless: 28 sources). Specific life-course and structural factors were evident for both groups, as well as commonalities with respect to: accumulated exclusions; complexity of needs; accommodation adequacy/stability and independence and resilience. Research gaps are identified concerning: lack of conceptualisation of positive health; the application of life-course perspectives and the absence of an environmental gerontological analysis of the situations of both groups.