1. A person who is sleeping in a place not meant for human
habitation, in an emergency shelter or is housed but losing
their housing within the next 14 days and has no support
network to remain in housing. People who are fleeing DV and
have no other residence.
(National Alliance to End Homeless 2012).

2.  It is estimated that 2.3 to 3.5
million people are homeless in the
US (Aron L, Lee E, 2011).
 In VA the Virginia Coalition to
End Homelessness, (VCEH)
surveyed 1,332 individuals:
 557 or 42% were identified medically
vulnerable
 1,929 emergency room visits in past 3
mo. (1,325 per visit), estimated cost
$10.2 m/year
 1,070 patients became inpatient after
ER visits in one year ($21,000 per
admission), estimated cost,
$22.47m/year.
• The VA homeless are 3-4x more likely to die prematurely than other Virginians
• In Richmond 46.2% of the homeless reported a long-term disability, 54%
reported a mental health disability.
• Between 10- 20% of total US homeless are Chronically Homeless.

3.  Conflict theory (Netting, Kettner, McMurtry, & Thomas, 2012) provides a view of the
homeless population and their need for services.
 In this economic downturn, funds are more difficult to come by for most social programs.
 Funding for homeless services is not adequate.
 In many social arena’s you may have the public assisting in the fight for minority rights
and services. This does not usually happen with the homeless. They are seen as unworthy;
substance abusers and money funneled their way contributing to their substance use.
 The policymakers can continue to overlook this group and there will not be loud voices
complaining and forcing them to action or even helping to make the problem visible.
 Policymakers many times focus on how to keep them invisible and/or enact policies that
move them somewhere else.
An example would be recent legislation in Henrico County not allowing loitering on the medians in
that county. The policy is targeted at the Homeless population, although it doesn’t explicitly
state that and uses the language of safety. They could have done something to help those in
need. Instead, they want them invisible in Henrico County, and have just moved them to
Richmond City who has no such policy.

4.  An unaccompanied person living in a place not meant for human
habitation (for example the street) or in an emergency shelter (HUD
2011). The person must have been continually homeless for 1 year or
more, or have had at least four episodes of homelessness in the past
three years. The person must have a disabling condition:
 Diagnosable substance use disorder
 Serious Mental Illness
 Developmental Disability
 Chronic physical illness or disability
 A combination of the above
 This must prevent an individuals ability to work or perform more than
one task of daily living (NOFA, 2010).

5.  There is an estimated 124,000 chronically homeless (CH) in the US. (NAEH, 2011)
 As the table shows 17% of the Virginian homeless are CH (NAEH, 2011):
 63% of them live on the street and more than 50% of services were used by them. (111th
Cong., 2009).
 They often cycle in and out of homeless
shelters, jails, hospitals, treatment
programs, the ER, MH services, veterans’
services and criminal justice resources.
 CH’ use a disproportionate share of
shelter beds and other public resources.
 The high use of the emergency
department can be explained by the lack
of primary care clinics and other medical
care entrance points. Many go to ER for
basic needs such as food, shelter and
clothing. (Kushel MB, 2001)

6.  The CH are extremely difficult to serve. They have often had a bad experience with
social services agencies and are therefore resistant to accepting help. They have worked
out that most services are not appropriate for them so there is little point in trying to
engage.
 In many cases homeless services are not physically set up to accommodate those with
high needs (physical, co-morbid disorders etc.). Most shelters don’t follow all the ADA
guidelines and very few have medical professionals on hand.
 Jahmel (Participant 1, 2012), explained that it was impossible to stay in shelters as he could not sleep in a
room with others, let alone a room with no doors. He says he feels less paranoid (a result of a Dx of
schizophrenia) sleeping alone in an alleyway “away from the undercover agents”.
 Bill73 in VA is a bill that is currently in the stages of being passed. It will require those
are in need to take drug screenings in order to receive public assistance (Hankerson,
2012)
 What will substance abusers do when they cannot get public assistance

7.  The Chronically homeless typically have little or no social
support and sparse contact with their families (usually due
to ties that have been torn as a result of their morbid, often
co-morbid disorders).
 Ricky (Participant 2, 2012) describes his social life as “always busy”, he
actually complains that he is rarely left alone to think and admits to
preferring solitude. Yet every time one comes across Ricky he is in
company. It is not unusual to have a high level of contact with others as a
CH individual, however that contact is usually with other CH’s. Although
limited social stimulation is gained from these relationships as Ricky states:
“Papi. they more likely be takin’ my check than let me have a puff of their
cigarette”.

8. The table shows how a CH person will
cost the community much more before
she/he is housed. Keeping people
homeless vs. housing them has a huge
benefit to the community (more on this
this later).
This has renewed VCEH’s effort to end
homelessness, but unfortunately for the
CH’s, the majority of the focus and
financial aid is being dedicated to work
towards preventing homelessness and
rapidly re-housing the recently
homeless.
 Case Manager positions for the homeless are being cut in favor of bringing on Community Case
Managers to work with those at risk of homelessness (OPEH, 2012). While this is an important part of
ending homelessness, it neglects to address those that are already on the street and who are therefore
at higher risk of lethality.
 The “Housing First” model (again described later) faces a huge barrier of a severe lack of housing, and
waitlists that can be several years long for Permanent Supportive Housing.

9.  It is important that any interventions to assist homeless people in
Richmond, Virginia include the voice of the target population.
 More than getting to know them and their needs, actually including
them in the solution (Netting, Kettner, McMurtry, & Thomas, 2012).
 In determining community characteristics it is important to note that
while most people consider the homeless population as homogenous in
that they are drug abusers and/or mentally ill; within the mentally ill
and substance abusing population of homeless people they are all very
different and have different experiences that have brought them to
homelessness.
 This is important to know in coming up with a solution or even
acknowledgement of the problem.
 These differences within group are important in determining how the
subgroups of homeless in Richmond, Virginia define their boundaries,
strengths, issues, problems, and values (Netting, Kettner, McMurtry, &
Thomas, 2012).

10.  Netting, Kettner, McMurtry, & Thomas (2012) discuss the importance of understanding
how oppression and discrimination has contributed to the problems of this group
including their homelessness as well as how it continues to disenfranchise them and
limit services available.
 The community structure for the homeless population is mostly negative from their point
of view.
 The homeless population does not have representation and voices to advocate effectively
for themselves.
 Most of the advocacy and interventions are imposed by others and most often based on
making them more invisible as opposed to truly assisting them.
 There is only one program in Richmond, Virginia that assists this population, that is
Virginia Supportive Housing.
 The homeless population while they have rights afforded them by laws, they don’t always
work out that way in reality. Sometimes providers are not respectful, nor compassionate
with their care.
 They may not provide necessary treatment because the person is homeless or provide a
treatment that requires follow-up beyond the capabilities of a homeless person. An
example would be a lifesaving surgery in a hospital, then releasing them to the street,
where infection will set in without a clean, stable environment to recover in. Are they
supposed to move? will they pull out stitches? etc.

11.  The “vulnerability index” is the new trend in
homeless services across the country (NAEH,
2012). It is not in place in Virginia yet, but it is
being discussed and plans are to put it in to
action in the future. Richmond was the first
city to join this state wide initiative. (Jean A,
2010)
 Instead of traditional outreach services, the
index will act as a survey, to collect data from
the CH in order to rank them on a scale of
vulnerability. i.e. Likely hood of dying on the
street within the next 12 months
 This tool frequently finds that the CH at
highest risk, have been homeless for over 20
years. It is currently being used in NYC and
LA, (Jean A, 2010).
 Focusing on the most vulnerable,
communicates that they are NOT beyond
hope.

12.  The Housing First Model is unlike the majority of homeless housing services,
individuals are provided with housing even before they are clean or engaged in
services. Once they move in, they are then provided with support:
 Sub. Abuse treatment MH treatment
 Education  Job training
 Placement assistance  Benefits assistance etc.
 The Intensive Community Treatment Team ICT in Fairfax County advocates
for housing first for their clients (even though in reality it means that there
often is a wait that lasts several months). However, once in their home, the
clients have been shown to have a greater success of holistic improvement with
the continued support of the multidisciplinary team (Ffx Co. Gov, 2012)

13.  Since being housed by the ICT team, Pat (Participant 3, 2012) has established medical care, got in
contact with his family and has stopped abusing alcohol, he is stabilizing with help from the ICT
Team, taking steps to deal with PTSD from Vietnam, abuse and 8 years in the woods.
 In Richmond programs such as Home Link, a program run by Virginia Supportive Housing, is putting
the housing first model in to action. Home Link is helping people who are at high risk of lethality to
survive, receive support, compassion and hope, even if in their last days (Fisher, 2012).
 In the early 2000s, the Millennial Housing Commission and the President’s New Freedom
Commission on Mental Health, estimated that approximately 150,000 new units of permanent
supportive housing were needed to end chronic homelessness.
 Since then, approximately 60,000 units have been created through HUD’s McKinney-Vento
Homeless Assistance Grants. This leaves another 90,000 still to be created, a task that will take
several federal policies to be put in place.

14.  Studies have shown that there is a notable health improvement in CH
clients who have been housed in supporting programs. The following
is an excerpt from a recent study, it shows the impact of permanent
supportive housing on homeless, HIV-positive individuals:
“In this randomized trial, we found that housing homeless HIV-positive
individuals and providing them with intensive case management can
increase the proportion surviving with intact immunity and decrease
overall viral loads. The 63% relative increase and 21% absolute increase
in survival with intact immunity is clinically meaningful. For every 5
patients offered this intervention and for every 3.25 patients provided
housing in a program agency, 1 additional patient will be alive with
intact immunity.” (Buchanan, 2009)

15.  Hospice is a medical specialty, focused on
providing care at the end of a persons life.
Helping them to be comfortable and to manage
their pain so that they can maintain dignity in
their passing.
 Hospice focuses on caring and not curing an
illness, the person must have a terminal illness
that even aggressive treatment will not cure.
 Hospice uses all the skills of a
multidisciplinary team that provide the
physical, psychological, social, spiritual and
other needs that are typical of the last stages of
life and during the dying and bereavement (see
diagram).

16.  It also provides numerous services to help loved ones come to terms
with their grief.
 In most cases the care is provided in the persons home, free standing
hospice centers, hospitals and nursing homes (NHPCO, 2012)
 Uninsured, terminally ill persons who are deemed by two Dr.’s to have 6
months or less to live are eligible for Medicare Part A (if they are US
citizens or legal aliens).
 They are then tasked with finding a palliative care provider that is
approved by Medicare.
 Informed consent must be given by a family member if the person is
unable to do so (Alexandra, Arenella et al, 1999)

17.  In 2010, an estimated 1.581 million patients received services from
hospice care. This included:
 1,029,0001 patients who died under hospice care in 2010
 292,7591 who remained on the hospice census at the end of 2010 (known as
“carryovers”)
 259,0001 patients were discharged alive in 2010 for reasons including extended
prognosis, desire for curative treatment, and other reasons (known as “live
discharges”).
 Over the past decade, the hospice industry has been marked by substantial
growth in the number of hospice programs and patients served. (NHPCO,
2012)
 The proportion of hospitals that offer dedicated palliative care programs has
grown significantly in the past decade, from 15% in 2000 to 25% in
2003.(Morrison, 2002). Academic medical centers, Veterans Affairs hospitals,
and Catholic hospitals are more likely to have palliative care services than
nonprofit or public hospitals. Homeless patients are more likely to receive care
in public hospitals, they are less likely to die in settings that offer palliative care
services.

18.  As per the above graph, the number of Medicare patients is increasing over time, this could be
due to many factors:
 Medicare is being made available to more people, including the homeless in need of palliative care.
 There are more people surviving to an older age, where hospice is more greatly needed.
 There are more Hospice care providers that accept Medicare:
 In 2010 there were more than 5,000 Hospice Care organizations in the US, over 220 in VA alone.

19.  Traditional palliative care hospitals may be reluctant to accept CH
patients, due to behavior or lifestyle concerns (Gelberg, 1992).
 Ricky is in adult incontinence pants now, but with out them, and without the ability to make it to a
rest room quickly on the street, he said he always felt shame asking for help. It was not unusual
for a member of the Social Services team to show “disgust” at how he presented: “it ain’t my fault, I
get anxious and”, he motions with his hands that he would lose control of his bowel. “I wonder why
hospice visit for such a short time, is it ‘cos I don’t understand what they are saying, or because I’m
just a homeless freak, it makes me depressed and I hate crying” he says as he wipes tears from his
eyes.

20.  Even with terminal illness, some CH remain in shelters due to the familiar environment,
or in order to keep using tobacco, alcohol or drugs. For many this is a form of self
medicating for their co-morbid conditions, regardless that a large majority suffer from
liver complications and are actively hastening their death.
 Ricky: “I got real good at sneakin’ it in to shelters, the truth don’t set you free, papi, I need my
jungle juice to function, I’ve been to so many rehabs, detoxed over and over. I know its not going to
help my liver, but what I got to live for? Am I going to give it up before I croak?- I don’t think so!”
(last part said very emphatically)
 Adherence to treatment in this population is often difficult, resulting in symptom
intensification and the need for crisis services (Podymow, Turnbull and Coyle, 2006)
 Many professionals offer potentially curative surgery, if the patient stop abusing
substances. The reasons to refuse surgery are often not explained to the patient, studies
have shown that often the rationale is both medically and ethically inappropriate. For
example, from the clinical standpoint, while heroin and cocaine use can complicate
anesthesia, neither is an absolute contraindication (Hernandez, 2005).

21.  It is not infrequent that a terminally ill CH patient is under prescribed pain medication at the
end of their life. Many times opiate addicts go through withdrawals after having been admitted
to the hospital. Heroin withdrawal, for example, can be prevented with opiate replacement
therapy (methadone, levomethadyl acetate, or buprenorphine).
 Physicians often admit that the fear of investigation, sanctioning, and even prosecution for
prescription of opioid analgesics can be a barrier to appropriate treatment of pain (Model
Policy for the Use of Controlled Substances for the Treatment of Pain, 2004).
 Living on the margins of society can widely change priorities, elevating some concerns
while at the same time lowering other essential priorities of self care. That being said,
there is no reason to believe that a CH at the end of life would not desire the same relief
from symptoms that a domiciled person would.

22.  Medical respite describes short-term shelter with basic medical services for homeless persons who are
too ill to function on the street but who don’t need hospitalization.
 Respite care models range widely, from homeless emergency shelters with part-time nursing care to
extended-stay facilities with physicians available. Respite availability decreases subsequent
hospitalization days. (Salt, Kuhn, 1998) Although most respite providers recognize the need for end-
of-life care, only a few programs address this issue. Unfortunately, most programs do not have
sufficient staffing to attend to the needs of patients nearing death (David Buchanan 2006).
 The Greater Richmond Homeless Respite Program provides 24-hour, short-term care to homeless
men and women with acute medical and mental health conditions but is not equipped to care for
those nearing the end of life.

23.  In a recent study it was shown that 60.7% of CH in hospice care were in
contact with their family, although this is considerably higher percentage to the
contact before a family learns of a terminal illness it does not reflect the nature
of the relationship. (Podymow, Turnbull and Coyle, 2006).
 It is relatively common for doctors in hospitals to make decisions for patients
with no family present. One third are known to have turned a ventilator off in
the absence of a next of kin (Karp and Wood, 2003).
 Jahmel is not in contact with any of his family, even though they live close by
in Richmond. Unlike many of his friends one of the major reasons he left
home was to get away from drug use.
 Dying at home is not a realistic goal for the CH at end of life, not only do they
often lack the literal shelter of a home, but as importantly they also lack the
companionship and social connections often associated with stable housing.

24.  Having spent years living on the street, it is understandable that CH may not
find it an easy task to accommodate to the rules and restrictions found in
skilled nursing facilities. They are often at the end stages of their lives at a
younger age than the general population and therefore often not comfortable
receiving care in facilities that cater to geriatric populations when they don’t
view themselves as elderly.
 With inappropriate care and housing, a large number of CH are found dead in
public places, others are found in residential dwellings, at home, arrive dead to
the emergency department, or die shortly afterward (Hwang, 1997).
 An article in the Reston Patch in December 2011 (a news blog for a city a few hours north of
Richmond) reads: “Police were called to the Springs apartments late Tuesday night after residents
of the neighborhood smelled a strange odor coming from a basement storage area. The body is
believed to be an adult male. Police said they do not yet know the man's identity or how he died.”
(Goff, 2011). The investigations were not extensive around this case, after it was discovered that
the body was that of a CH elderly gentleman.

25.  Song et al. (2007a) conducted a study to identify experiences and attitudes about death and dying by
homeless people. Many homeless people as a result of their life experiences think that any care they receive
will be substandard, this includes how they feel hospice and palliative care will be provided.
 Song et al. (2007a) showed that homeless people have experiences of early loss in their lives that have led
many to have a fatalistic attitude. Homeless people had often had multiple experiences with death, including
personal experience with death or that of a relative, friend, or street friends. Frequently their experiences
involved traumatic and anonymous death, especially of street friends.
 It was also discovered that many of the homeless population have omnipresent thoughts of death because it is
a part of their everyday lives. The homeless live in fear of daily death which has shaped their coping
mechanisms. Many of the homeless people in the study were emotionally detached and isolated as a result of
living a life with personal life-threatening situations and their daily fear of death (Song et al., 2007a). Two
contradictory styles emerged:
1. Some homeless people were a lot more careful of their behaviors and lived in survival mode and
attempted to find as much safety in their situations as possible, including the behaviors they engaged in.
2. The other style produced more risky behavior. Those in this group engaged in risky behaviors and
believed the behaviors were reasonable based on their situation. This group perceived death as
unavoidable, therefore it did not really matter what they did. In fact many of the homeless people stated
that they engaged in risky behaviors such as drinking and drug use to forget about the unavoidability of
death as an everyday eventuality (Song et al., 2007a).

26.  CH’ emerging themes in attitude toward end of life (EOL):
 Loss of control
 Belief that services are not required.
 Belief that interventions were imposed and not wanted.
 Desire for compassion at EOL from individuals (widely defined by different CH as friends
from the streets to service providers), (Song et al. 2007b)
 Suggestions from CH:
 Education to Homeless providers for more culturally sensitive interventions and care.
 Advance care planning and documentation to remain in control and have their wishes
known and respected.
 Hospice populations that are suited to this populations special needs (Song et al. 2007b).

27.  If adequate services are created there will be
difficulties in linking the population with them.
 How can you coordinate services for a population with
limited communication means?
 Can you call them to inform them of appointments if that
information is not available at discharge?
 Will the provider they are referred to accept the homeless
person the way they present for care?
 Due to negative past experiences with the limited
providers in the area, will the homeless person even
attempt to access a service that has not worked out in
their favor previously?

28.  Considering the heavy burden of disease including physical illness, psychiatric
conditions and addictions among the CH at end of life. If palliative care could
be brought to the shelter environment it could provide effective end-of-life care
and as discussed earlier, potentially substantial cost savings.
 Ricky explains that most hospice programs that had availability and accepted
Medicare were far away from home. Ricky is blind in one eye and illiterate, so being in
familiar surroundings and able to orient himself was extremely important to him.
Also the fact that his friends had no means to get to see him if he moved away was
another fear of his: “I get very lonely, papi, a blonde would be nice, but my friends are
all I got”. He was offered a place at Josephs house in DC, but turned it down, because
he could not cope to “be lost in my last days”. Ricky is one of those lucky clients who
were able to get in touch with his family and move in, with the care of hospice. Still he
often complains of being bored at home in a room on his own and often contemplates
the streets as a better option. One time he walked 4 miles back to the shelter (a man
in the last stages of liver cancer) to see his friends. He also feels guilt at being housed:
”last night there was a storm, and as I looked outside I thought of my crew”. He
systematically recalled all the safe spots (that would be taken first), the ones that
would gather puddles, the ones where water would run through etc.: “I kept thinking
they probably need an extra blanket and tarp tonight).

29.  Increasing low-barrier shelters that not require guests to be sober or
participate in programs to receive aid could increase the number of CH
seeking shelter, especially those in need of palliative care.
 At present Richmond offers only one overnight shelterthat provides
low barriers for entry to homeless men, even if they are under the
influence of drugs and/or alcohol. Most of Richmond’s shelters will
not admit these individuals. The shelter is within the same setting
as the recovery program. Here the active alcoholic or addict has an
opportunity to come into contact with his peers who are in recovery.

30.  Some studies have found that homeless persons expect their deaths to be sudden and
violent (Song 2005). Because of this, they may be less willing to discuss end-of life-
planning.
 A New York Times article from December states:
 “The final version of the health care legislation, signed into law by President Obama in March,
authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule
says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as
part of the annual visit.” (Pear, 2012).
 The question is, will the CH take advantage of this?
 The “Five Wishes” (Aging with Dignity, 2011) is a booklet that is being made more widely
available. It it systematically goes through some important end of life scenarios and gives
the opportunity for a person to make decisions about their treatment in advance in the
event that in the future they will be cognitively unable to do so themselves. It is extremely
important that this is made available to the CH in end of life care.

31.  Harm Reduction is a concept that is being practiced world wide to promote health and
dignity among drug users, those involved in the sex trade and their communities. It is
designed to reduce harmful consequences of behaviors rather than prohibit behaviors
themselves. I.e. provide clean syringes and safe injection sites to heroin users.
 There is a Harm Reduction Coalition Group in Richmond that advocates for the advancement of
harm reduction policies, recognizing that inequality and injustice increase drug related harm
and silence the most vulnerable in the community (www.harmreduction.org).

32. The Ottawa Inner City Health Project (OICHP)
 A Hospice 15-bed shelter pilot program for the CH at the end of life, that was
created in June 2001.
 Shelter provided meals, beds, a full multidisciplinary team dedicated to working
together to serve the clients 24hrs a day, 7 days a week.
 Harm reduction was practiced, providing clean needles, safe syringe disposal. a
smoking area, dispensing of 14g drinks of alcohol on demand to alcoholic clients.
 Results:
 Harm reduction and proper pain control managed by staff reduced substance use in clients,
particularly the illicit intravenous drug use.
 Pain was successfully controlled in all 28 clients who were served and died at the program.
 The majority were reunited with their families, many of them had not had contact with them for
many years.
 Clients all required considerable assistance with all daily living skills, which they received by the
hospice team.
 Spiritual council was received by most clients.
 It was agreed by the researching panel that 68% of clients might not have sought care or received
services, most of them probably dying homeless without symptom management.
 It was projected that compared to alternate locations the OICHP saved $1.39 million for the clients
they served.
(Podymow et al., 2006)

34.  It will be also be important for those involved to be prepared for how
stigma associated with the homeless population will impact funders
and community provider’s willingness to participate in the
development of a new facility.
 The importance of challenging stereotypes with physical examples,
statistics, and education will prove to be incredibly important in
educating those not directly working with the homeless population of
the importance of and need for end of life care for the chronically
homeless.

35.  The writers recommend a change approach that focuses on the development of
a community-based hospice program for chronically homeless individuals with
terminal illness.
 We have chosen to focus on all individuals with terminal illness, but with a
special focus on those who are too medically vulnerable to meet the
requirements of shelter living or meet the intake requirements of Medical
Respite.
 Positive results should mean that the metro-Richmond area will see:
 A decrease in the number of chronically homeless individuals dying on the street,
 A decrease in the number of acute hospital admissions for chronically homeless
individuals needing long-term palliative care,
 An overall reduction in spending associated with acute medical care that could be
managed in a community-based palliative setting.

36. The following goals, outcome objectives, and process objectives have been set for
the program: .
Goal 1

37. Goal 2

38.  The writers and staff of the new facility, would focus on providing
education about new hospice alternatives for those identified as
chronically homeless with end-stage illness.
 Education would remain facility based and would continue on a
quarterly basis, or more frequently if identified as necessary.
 The new facility would hire a liaison between the program and
community-based agencies to ensure a central contact for questions
regarding referrals, intake procedures, patient appropriateness, and
community-based facility expectations after admission. .