Housing instability complicates end-of-life care for aging unhoused populations

Research estimates that one-third or more of the unhoused population in the U.S. is age 50 or older.

Unhoused people of all ages face high rates of chronic and serious illness. They also die at younger ages compared with people who are not unhoused.

Yet, there are few options for palliative and end-of-life care for unhoused people.

Palliative care is a type of medical care that addresses pain, symptom management and the social and emotional needs for people with a serious illness, such as cancer.

End-of-life care, such as hospice, is a type of palliative care for someone in the terminal stage of an illness and nearing the end of their life.

As a health care and aging researcher, I focus on social and policy issues that impact how people experience illness and who has access to the care they need. In my recent study, I interviewed 17 health care and social service providers in Colorado to understand how they try to address palliative and end-of-life needs for their unhoused clients.

In 2024, Colorado saw a 30% increase in the number of people experiencing homelessness from the year before. Nationally, 771,480 people — the highest number ever recorded — experienced homelessness last year.

As the number of people experiencing homelessness in the U.S. grows, so too does the need for palliative and end-of-life care for these individuals.

Palliative care is more available to people who have access to stable housing, good social support and health insurance. But people who are unhoused often lack social support and face discrimination within the health care system. In fact, it is common for people experiencing homelessness to die outside, in homeless shelters or in hospitals.

“We’re dealing with an inhumane lack of resources,” said one provider I interviewed.

Providers like this one described few good options for hospice placement for unhoused patients. They cited a lack of collaboration between health care and homeless services to coordinate care, and staffing shortages across health care and homelessness service providers, all of which made it difficult to provide care to unhoused people with serious illnesses.

Other studies have also found an overall lack of palliative resources for unhoused individuals across the U.S. and in other countries. Those include financial barriers for health care institutions to provide care to those without insurance coverage, a lack of palliative care knowledge among health care and homeless providers alike, and homeless shelters that are not equipped to support end-of-life care for residents.

“Shelters are not designed to take care of people like this. Hospices are also not designed to do this,” one provider said. “It’s a gap of care between the two organizations, and they really struggle with it.”

Many people experiencing homelessness are eligible for long-term care Medicaid benefits that will help pay for hospice in a nursing facility. However, long-term care and nursing facilities often have a limited number of beds available for Medicaid recipients and may even refuse unhoused patients.

Despite the lack of resources in Colorado and across the U.S., the providers I interviewed said they try to care for unhoused patients with humanizing approaches.

“Everyone is deserving of care,” said a medical social worker during one of the interviews. “Health care, housing – those are human rights, in my opinion.”

The providers prioritized building rapport and trust between homeless service providers and unhoused clients, and honoring the dignity and autonomy of these individuals.

“The approach we take is patient-centered …” one provider said. “It’s about showing someone respect no matter what’s going on socially in their life, and proving to them that you care, and showing up.”

One way that providers showed respect was by advocating for their unhoused clients when they noticed that colleagues or other agencies involved in their care were neglecting their needs or using stigmatizing language to talk about their clients.

“We try really hard to humanize these people because usually they’ve done some amazing stuff. … ‘Did you know that this person did this?’” one provider said. “So that it changes people’s automatic ‘She’s just a bipolar, homeless frequent flyer’ and trying to take away those labels. We love to find the gems and share them, because it stops people in their tracks.”

Another provider said, “We do a really good job of meeting people where they’re at, give them the choice of how much or how little support they want.”

Several providers described ways their agencies were trying to make positive change – for example, providers working within a hospital created a new service dedicated to providing case management to unhoused patients.

In Denver, several health systems have launched initiatives to try to fill the gaps in health care for their unhoused patients. For example, UCHealth and Denver Health have processes dedicated to improving discharge planning, connection to housing services and care continuity for unhoused patients with health needs.

To better meet the palliative needs of unhoused Coloradans, several providers suggested more specialized palliative care services that exclusively serve unhoused patients. This could include mobile palliative care services that meet people at a shelter or on the streets.

Research has found that specialized health care in general is more effective and affirming for unhoused individuals than traditional health services. Examples of such specialized palliative programs in the U.S. and internationally include the Rocky Mountain Refuge, the INN Between and the Harborview Homeless Palliative Care Team in the U.S., and Palliative Education and Care for the Homeless in Canada.

My study suggests that a deeper compassion for patients experiencing homelessness, palliative or not, is an important approach for health care organizations and their providers to take, even when resources are sparse. This approach can lead to better patient satisfaction and improve health outcomes for unhoused people.

Another solution — and one that starts before unhoused people need palliative care — is better housing solutions. Providers said many of the gaps in care for unhoused people would be solved if housing were more affordable and accessible.

Read more of our stories about Colorado.

This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world. It was written by: Pilar Ingle, University of Denver

Pilar Ingle is affiliated with Senior Support Services, a Denver-based day shelter for low-income or unhoused older adults.