Intersection of Homelessness, End of Life, Substance Use and Mental Illness: Challenges for Homeless Veterans and Providers

Special Article - Palliative Care

Ann Nurs Res Pract. 2017; 2(1): 1014.

Intersection of Homelessness, End of Life, Substance Use and Mental Illness: Challenges for Homeless Veterans and Providers

Weber M¹*, Jones J¹, Albright K², Dischinger H³, Levy C³, Hutt E³ and O’Toole T4

¹University of Colorado College of Nursing, USA

²University of Denver, USA

³Eastern Colorado VA Health Care System, University of Colorado School of Medicine, USA

4Providence Veterans Affairs Medical Center; Brown University School of Medicine, USA

*Corresponding author: Mary Weber, University of Colorado College of Nursing, 13120 E. 19th Ave, Aurora, CO, 80045, USA

Received: January 15, 2017; Accepted: February 13, 2017; Published: February 15, 2017


Homeless Veterans at the end of life and the providers who serve them face a many challenges. In addition to the simultaneous demands presented by being both homeless and end of life, many Veterans also struggle with substance use and/or psychiatric disorders. Navigating the intersection of these challenges is complex, but unpacking the competing issues and identifying areas of overlap is critical to serving this vulnerable population. Using a three phase sequential mixed methods design the authors 1) surveyed homeless and end of life programs affiliated with the Department of Veterans Affairs (VA); 2) conducted interviews and focus groups with 136 Veterans with unstable housing and multidisciplinary VA and community staff in five cities in the United States (US); and 3) held a forum with national stakeholders to identify specific educational and policy recommendations to improve care. This paper reports on one of the most significant barriers to care to emerge from these data: the complexity of pain management in this population. Recommendations to address this complex interaction of care are discussed.

Keywords: Homeless veterans; Homeless and end of life; Pain management; End of life; Substance use


HV: Homeless Veteran; EOL: End of Life; VA: Department of Veteran Affairs; US: United States; PTSD: Post Traumatic Stress Disorder; TBI: Traumatic Brain Injury; HSR&D: Health Services Research and Development; FG: Focus Group; IRB: Institutional Review Board; HVI: Homeless Veteran Interview; KII: Key Informant Interview; FGP: Focus Group Participant; NPDF: National Program Development Forum; VASH: Veteran Affairs Supportive Housing


More than 500,000 people are homeless on a given night, according to 2014 data from the United States Department of Housing and Urban Development. Of these, almost 70% are in residential programs, and over 30% are living on the streets [1]. For many in this population, managing the difficulties presented by unstable housing are often compounded by the added burdens of chronic physical, mental, and substance problems [2,3]. In a recent survey of homeless adults conducted by the lead author, approximately 43% described a serious/chronic physical health problem, 53% a serious mental health problem, and 49% a substance use disorder [4]. Adults experiencing homelessness are estimated to have mortality rates 3-5 times higher than the general population [5,6]. Even with this higher level of mortality, there is very little data on the end of life needs for homeless adults in general, with even less data available on homeless Veterans specifically.

Kushel and Miaskowski [7] were among the first researchers to identify the medical complexities of homeless individuals who need End of Life (EOL) care. Most respite facilities, which are designed to provide temporary shelter and care for people with medical problems who are without housing, have neither the staff nor knowledge to care for homeless individuals at the EOL. McNeil and Guirguis- Younger [8] conducted a qualitative study of EOL challenges faced by Canadian homeless individuals with substance use issues. Major themes included competing priorities with drug/alcohol withdrawal and treatment, significant discrimination, and lack of trust in health care providers.

Although homeless Veterans make up approximately 15% of the homeless population [9], this subpopulation has only relatively recently attracted attention from researchers [8,10,11]. There are many VA services for homeless Veterans as well as for Veterans in need of palliative or EOL care; there are no specific programs for those homeless Veterans and in need of palliative care or EOL care. Providing EOL care is difficult even without the added challenges of homelessness and/or substance use. In addition, little is known whether Veteran status and associated stressors such as chronic mental illness, Post-Traumatic Stress Disorder (PTSD), and Traumatic Brain Injury (TBI) have an impact on EOL care. The results of a survey of VA programs (available in the published manuscript) completed by the authors, indicated that EOL needs for housing was a significant barrier for this sub-population of homeless Veterans [12].

The pilot study conducted by the authors [12], led to the development of the parent research study [13-15,]. The purpose of this parent study was to develop a deep and broad understanding of the barriers to and facilitators of excellent EOL care for veterans without homes and define the key structural, clinical and policy elements required to improve care. In 2012, the VA Health Services Research and Development (HSR&D) funded this three-year research project. The results from this study, described in detail in other presentations or manuscripts [13-17], included five barriers to quality EOL care. The authors then completed a secondary data analysis on one of these barriers, the challenge of symptom management, to further explore this theme. In this paper, the authors discuss the results of this secondary data analysis regarding the intersection of homelessness, EOL needs, substance use, and mental illness for Veterans and the providers who serve them. Recommendations to address these issues are discussed.

Materials and Methods

The HSR and D funded study [13] was structured according to a three phase sequential mixed methods design in which the authors: (1) surveyed homeless and EOL programs affiliated with the VA [12]; (2) conducted interviews and focus groups with 136 Veterans with unstable housing and multidisciplinary VA and community staff during site visits to five U.S. cities [13,14]; and (3) convened a forum with national stakeholders, including representation from each Focus Group (FG) and national leaders in homeless and palliative care, to identify specific educational and policy recommendations to improve care (Figure 1). Institutional Review Boards (IRB) at the Central VA, the University of Colorado, and the local site VA Research and Development committees approved this study.