Homeless People

Homeless People

The following resources may be useful in planning and providing appropriate end-of-life care for homeless persons particularly co-ordinating care between health and community service providers.

Practice issues

Mann E. JBI Evidence summaries: Clinical Risk Management: Homeless Older Person. 2013.
This document is available through a subscription only service. The evidence summaries can be located on the Joanna Briggs Institute website.

Kennedy P, Sarafi C, Greenish W. Homelessness and end of life care resource pack: practical information and tools to support the needs of homeless people who are approaching the end-of-life, and those who are bereaved. 2013. Marie Curie Cancer Care and St Mungo’s UK (freely accessible).
This resource pack is specifically designed to enhance the skills and knowledge base of managers and frontline staff working with homeless people. This includes those working in supported accommodation, assertive outreach, drug and alcohol services, and homeless day centres. The pack is also intended to assist professionals working in hospitals, GP surgeries, palliative care services and social services who provide health or social care to people experiencing homelessness who are approaching the end of their lives or experiencing bereavement.

Palliative Care Australia. Standards for Providing Quality Palliative Care for all Australians. 2005. (freely accessible 633kb pdf).
Information is provided in this document about palliative care for people experiencing homelessness. 

Kinderman A, O'Connell JJ. Palliative care for homeless persons. 2018. 
This extensive, peer reviewed review examines the published literature in order to inform care of homeless patients with serious illness, including goals of care and management of common symptoms. Although US based many topics covered are relevant to the Australian context.

Policy and management considerations

Department of Families, Housing, Community Services and Indigenous Affairs. The road home: A national approach to reducing homelessness. 2008. (freely accessible).
This paper addresses the causes of homelessness and provides a framework for preventing homelessness from occurring in the first place. Among other strategies it increases support for victims of domestic violence to stay safely in their own home; increases public and community housing for people at risk of homelessness; improves tenancy advice and support services; and introduces a policy of ‘no exits into homelessness’ from hospitals, mental health and drug and alcohol services and statutory care. These measures will help prevent more Australians from becoming homeless each year.

Department of Health and Aged Care. Specialised homeless status approved provider application form. Current (freely accessible online resource).
To assist aged care homes that specialise in caring for people who were homeless or at risk of becoming homeless, the Australian Government offer a Homeless Supplement for aged care under the AN ACC funding model. 

Associated materials

Hudson BF, Flemming K, Shulman C, Candy B. Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research. BMC Palliative Care. 201615:96 DOI: 10.1186/s12904-016-0168-6.
This review presents a synthesis of published qualitative research exploring from the perspective of homeless people and those working to support them, current challenges to palliative care access and provision, in addition to suggestions for what may improve palliative care for this population.

Connelly L. An economic evaluation of the homeless to home healthcare after-hours service. 2013. (freely accessible 8MB pdf).
This report evaluates a Brisbane-based health and housing model. The service integrates nurses with homeless outreach teams to provide healthcare to homeless and vulnerably housed individuals while also ending their homelessness. The net benefits of the Homeless to Home Healthcare After-Hours Service are positive: its benefits outweigh its costs, whether or not the scope of the evaluation includes only hospital system costs or is extended to include the monetised benefits of improvements in health-related quality-of-life. The Homeless to Home Healthcare After-Hours Service therefore appears to be in the class of dominant interventions (ie, that class of interventions that not only improves health, but also does so at lower cost than the alternative). It has been estimated that between 8% and 20% of published evaluation fall into this category, with the remainder of interventions either costing more per unit of health gain, or costing more and producing no additional health gain.

Gronda H, Ware V, Vitis L. What makes a difference? Building a foundation for nationally consistent outcome measures. 2013. Australian Housing and Urban Research Institute, HomeGround Services, Hanover Welfare Services, Melbourne Citymission. (freely accessible 3.5MB pdf).
This project sought a solid, credible basis for measuring the effectiveness of homelessness services. From the underlying evidence, the project built a model of the steps needed to achieve results. The model, a ‘client outcomes model’, and the research synthesis that underlies it, provide a comprehensive guide to effective practice and a rigorous basis for nationally-consistent client outcome measures. The research draws on three strands of evidence: research findings about homeless populations and service delivery, theoretical frameworks for outcome measurement, and findings from homelessness sector outcome initiatives. The project identified convincing reasons for establishing nationally-consistent client outcome measures, as well as significant challenges. Benefits include providing direction, focus and driving innovation. Challenges include capturing the complexity and diversity of service delivery practice, and the fact that inappropriate outcome measures can lead to ‘fudging’ results or poor morale. The project also found that an evidence-based ‘outcomes model’ could provide a way to manage the challenges, while delivering the benefits of nationally-consistent outcome measures.

Ko E, Nelson-Becker H. Does end-of-life decision making matter?: Perspectives of older homeless adults. Am J Hosp Palliat Care. 2014 Mar;31(2):183-8.
This qualitative pilot study explored perspectives, needs, and concerns relating to advance care planning among older homeless adults. Key emergent themes included discomfort with the topic, trust in God's decisions, physicians preferred as decision makers, and planning is important but not an immediate concern. Further, people who are homeless want to be approached with sensitivity. Instead of simply eliciting life-sustaining treatment preferences of homeless people, health care professionals should assess their unique concerns and needs regarding death and dying, prepare them to consider their possible end-of-life situation, and assist them to plan in accordance with their needs.

MacWilliams J, Bramwell M, Brown S, O'Connor M. Reaching out to Ray: Delivering palliative care services to a homeless person in Melbourne, Australia. Int J Palliat Nurs. 2014 Feb;20(2):83-8.
This paper describes a quality-improvement project undertaken by a community-based palliative care service in Melbourne, Australia, to understand homeless people's palliative care needs and the challenges that workers face. The results were used to initiate discussion about how policy and protocols for the community-based palliative care service might serve this population more effectively. The findings confirmed that homeless people have complex psychosocial and medical needs. They may be periodically uncontactable or living in unsafe settings, experience isolation from social support networks, and have issues of compliance with treatment protocols exacerbated by mental health problems and/or substance abuse. Service providers had particular challenges in meeting the palliative care needs of homeless people.

McNeil R, Guirguis-Younger M, Dilley LB. Recommendations for improving the end-of-life care system for homeless populations: A qualitative study of the views of Canadian health and social services professionals. BMC Palliat Care. 2012 Sep 15;11:14. (free full text article).
This qualitative study involving health and social services professionals from across Canada sought to identify barriers to the end-of-life care system for homeless populations and generate recommendations to improve their access to end-of-life care. Participants identified key barriers to end-of-life care services for homeless persons, including insufficient availability of end-of-life care services; exclusionary operating procedures and poor continuity of care. Participants identified recommendations that they felt had the potential to minimize these barriers, including adopting low-threshold strategies (eg, flexible behavioural policies and harm reduction strategies); linking with population-specific health and social care providers (eg, emergency shelters) and strengthening population-specific training.

McNeil R, Guirguis-Younger M, Dilley LB. Shelter-based palliative care for the homeless terminally ill. Palliat Med. 2006 Mar;20(2):81-6.
The homeless have high rates of mortality, but live in environments not conducive to terminal care. Traditional palliative care hospitals may be reluctant to accept such patients, due to behaviour or lifestyle concerns. The Ottawa Inner City Health Project (OICHP) is a pilot study to improve health care delivery to homeless adults. This is a retrospective analysis of a cohort of terminally ill homeless individuals and the effectiveness of shelter-based palliative care. As proof of principle, a cost comparison was performed. Burden of illness was assessed by medical and psychiatric diagnoses, addictions, Karnofsky scale and symptom management. An expert panel was convened to identify alternate care locations. Using standard costing scales, direct versus alternate care costs were compared. The homeless terminally ill have a heavy burden of disease including physical illness, psychiatric conditions and addictions. Shelter-based palliative care can provide effective end-of-life care to terminally ill homeless individuals at potentially substantial cost savings.

Song J, Ratner ER, Wall MM, Bartels DM, Ulvestad N, Petroskas D, et al. Effect of an end-of-life planning intervention on the completion of advance directives in homeless persons: A randomized trial. Ann Intern Med. 2010 Jul 20;153(2):76-84.
The objective of this study was to determine whether homeless persons will complete a counselling session on advance care planning and fill out a legal advance directive designed to assess care preferences and preserve the dignity of marginalized persons. Prospective, single-blind, randomized trial comparing self-guided completion of an advance directive with professionally assisted advance care planning was conducted on 262 homeless persons recruited from 8 sites. A minimal, self-guided intervention consisting of advance directive forms and written educational information versus a one-on-one advance planning intervention consisting of counselling and completing an advance directive with a social worker. The study found that both a simple and complex intervention successfully engaged a diverse sample of homeless persons in advance care planning. Homeless persons can respond to an intervention to plan for end-of-life care and can express specific preferences for care or a surrogate decision maker, but additional studies are needed to assess the effect of these directives on subsequent care.

Tarzian AJ, Neal MT, O'Neil JA. Attitudes, experiences, and beliefs affecting end-of-life decision-making among homeless individuals. J Palliat Med. 2005 Feb;8(1):36-48. (abstract only)
This study sought to increase health care professionals (HCP) awareness and understanding of homeless or similarly marginalized individuals' end-of-life experiences and treatment preferences. The study found that there was five main themes emerging: valuing an individual's wishes; acknowledging emotions; the primacy of religious beliefs and spiritual experience; seeking relationship-centered care; and reframing advance care planning. The narrative process of this qualitative study uncovered an approach to end-of-life decision-making in which participants' reasoning was influenced by emotions, religious beliefs, and spiritual experience. Relationship-centered care, characterized by compassion and respectful, two-way communication, was obvious by its described absence-reasons for this are discussed.

Page updated 11 April 2023