Barriers and facilitators to end of life care for homeless veterans

Introduction: Veterans are overrepresented among the homeless population in the United States (US). The Department of Veterans Affairs (VA) estimates that 14% of homeless adult males are veterans; approximately 1% of male veterans are homeless. Homeless veterans are at high risk for multiple physical, behavioral and substance-related illnesses, including cancer and heart disease.  End of life (EOL) care brings particular challenges to this population.  Veterans who are both homeless and at the EOL do not fit easily into existing programs.  This VA-funded research project aims to develop a broad and deep understanding of the barriers to and facilitators of providing excellent EOL care for homeless Veterans nationally. 

Methods: Using a two phase sequential design we 1) surveyed VA homeless and EOL programs and 2) visited four cities with sizable homeless populations, where we conducted interviews, focus groups and key stakeholder conversations with veterans, multidisciplinary providers and program leadership at the community and VA system level.

Results: There are important structural and interpretive differences between homeless and EOL programs. Interviewees and focus group participants emphasized the following themes.  (1) Housing for homeless veterans that relies on ‘clean and sober’ models or functional independence conflicts with the growing number of homeless veterans whose declining health prevents  living alone or realistic plans to abstain. (2) Pain management in the setting of addiction and end of life care is very challenging. (3) Discontinuity of care between systems and limited after-hours access to health professionals restricts EOL care delivery. Potential policy changes, collaborations and programs to facilitate high quality EOL care to homeless veterans will be explored.