UNIQUE CHALLENGES OF AGING IN PLACE FOR VETERANS

Specific Aims:

The aim of this presentation is to describe some of the unique challenges related to aging in place for Veterans as they face the end of life.

Interview schedule: •       What are the issues in providing (receiving) health services to homeless veterans?  •       What aspects work particularly well? When does the system not work well? How effective is the VA in providing end of life care? What do you think the goal should be in providing end of life care to homeless veterans? In an ideal world what would a program of end of life care for homeless veterans look like?

Rationale:

The 2014 IOM report Dying in America : Improving quality of life and honoring individual preferences near the end of life ¹identifies that ‘no one really knows whether, in the end, the death of a loved one occurred with the dignity that was hoped for, or to what degree the

dying experience was marred by pain, fear, and discomfort, emotional or physical.’ Veterans can be very vulnerable as they progress to the end of life, due to a disproportionate presence of mental disorders, particularly if they are homeless.² Continuity of care, isolation and a lack of advance care planning are just a tip of the iceberg for this population as they age in place and who are often unable or reluctant to access Veterans Administration (VA) health care services.

Methods:

As part of a national study to define excellent palliative care for homeless veterans, individual semi structured qualitative interviews lasting 60-90 minutes were conducted with homeless veterans and key program stakeholders in Denver, CO and Providence, RI to explore barriers and facilitators to care provision (see text box).  Using a snowball sampling approach participants were identified from a variety of VA homeless and palliative care contexts. Veterans self-identified as being ‘homeless’ also volunteered for interview from outreach settings.  Qualitative theme analysis was applied to the textual data about the anticipated challenges of care provision and self-management related to aging in place at the end of life.

Results:

Homeless Veterans (n=8) and key program stakeholders (n=8) identified 1) A safe and reliable place to be, food to eat; 2) Primacy of shelter where services can be delivered; 3) Reduction in stigma of Homelessness; 4) Adequate and effective program resources; 5) Flexible approach to determining veteran needs are key elements to improving palliative care delivery to homeless veterans.

Implications:

The findings augment understandings of palliative care and the aspiration of aging in place when one’s place is ‘of no fixed, regular and adequate nighttime residence’.² The study offers new perspectives on how to approach palliative care when uncertainty and flux are inevitable. Next steps include validation of these initial findings through field studies at six VA locations across the US and the development of policy, education and pilot program initiatives with key stakeholders.