Patient Perspectives on Palliative Care Outreach to Adults Living With Homelessness.

Introduction

Internationally, persons experiencing homelessness face substantially higher rates of early mortality. 1 , 2 , 3 , 4 In Canada, their life expectancy is 30 to 40 years shorter than that of adequately housed individuals. 3 , 4 Adults experiencing homelessness also have higher levels of multimorbidity and unique end-of-life symptom burdens. 5 , 6 Despite this, they face substantial structural barriers to accessing palliative care. 7 , 8 , 9 , 10 These barriers include stigma from health care -professionals, inflexible health care systems, insufficient training of health care professionals, and a lack of appropriate care environments. 7 , 8 , 9 In response, the past 2 decades have seen the development of outreach programs for persons experiencing homelessness in several countries. 1 , 11 , 12 , 13 , 14 These programs provide psychosocial and medical palliative care in settings where homeless adults live or seek services. 13

However, the scale of these programs remains limited, operating in only a few regions worldwide. 1 , 11 , 12 , 13 , 14 One barrier to replication and scale-up is the difficulty in assessing their direct benefits for individuals experiencing homelessness. Such persons are often considered hard to reach in health research. 15 , 16 As a result, research on this subpopulation tends to rely on health care professionals’ perspectives. 1 Yet in palliative care, patient-reported experiences of well-being are a critical measure. A recent systematic review identified only 1 study, a case report, that assessed a palliative intervention for adults experiencing homelessness based on the experiences of those receiving care. 1 , 17

The present study examined the Palliative Education and Care for the Homeless (PEACH) program, a community-based palliative care program for people experiencing homelessness in Toronto, Ontario, Canada, through interviews with PEACH patients. We asked how people living with homelessness and life-limiting illness experience the strengths and weaknesses of a community-based palliative care outreach program. We assessed patient-reported physical, psychological, and social factors associated with PEACH, the barriers participants faced, whether PEACH helped overcome barriers, and potential improvements for palliative care outreach programs. This is the first study, to our knowledge, to assess a palliative care outreach intervention from the perspective of people experiencing homelessness, and the results have implications for future program design and implementation.

Methods

Ethics Approval

Institutional ethics approval for this qualitative study was obtained from Unity Health Toronto. This study is reported according to the Consolidated Criteria for Reporting Qualitative Research ( COREQ ) reporting guideline. 18 All participants provided written informed consent except in the limited circumstance that a participant was unable to provide written consent without assistance, in which case the consent form was reviewed with the participant and then verbal consent was obtained and documented on the consent form.

Study Setting

The PEACH program is a mobile, street, and shelter-based interprofessional team of palliative care physicians, psychiatrists, social workers, and nurses who collaborate with health and social service organizations across Toronto, Ontario. Since its founding, PEACH has served over 1000 patients experiencing homelessness. It provides palliative and psychiatric medical care, connects patients with publicly funded home health care supports, helps secure housing, covers health care and medication gaps, and coordinates care with other community and medical supports. 14 , 19

PEACH serves unsheltered and vulnerably housed individuals, including those in shelters, government housing, temporary accommodations, and other precarious settings. 20 Most PEACH patients, and all study participants, meet the Canadian definition of homelessness. 21 Referral criteria include a life-threatening illness, substantial symptom burden, and difficulty accessing mainstream palliative care.

Study Design

We conducted an interpretive qualitative description study, well suited to research aiming to inform policy and practice, as it captures participants’ experiences in their own terms. 22 , 23 This design is also appropriate for exploratory studies describing a phenomenon rather than generating theory. 22 , 23 As the first study, to our knowledge, to examine patient experiences with palliative care outreach, this approach facilitated an inductive analysis and descriptive summary. The research team included qualitative health research experts (J.B.), palliative care specialists (J.M.B, D.S., N.D., and T.M.), and medical trainees (V.V,) with extensive experience working with structurally vulnerable populations in clinical and research contexts.

Participant Recruitment

Participants were initially recruited through purposive sampling of PEACH patients reflective of the overall PEACH patient population. Recruitment was challenged by medical and social instability, which made interviews difficult to schedule and often cancelled. The team then shifted to convenience sampling, approaching patients when they were stable enough to complete interviews. All patients were approached by PEACH staff, and those interested were later contacted by 1 of 3 members of the study team not involved in patient care (A.R.L., J.M.B., and V.V.), who obtained consent and conducted interviews (eMethods 1 in Supplement 1 ). Participants were adults over 18 years of age, English-speaking, and able to independently answer interview questions. After their interview, each participant received a $20 coffee shop gift certificate as honoraria, consistent with standards in homeless health research. 24 , 25 , 26

Data Collection

Data were collected between May 1, 2023, and November 30, 2024, through semistructured one-on-one interviews, conducted in-person when possible or by phone when necessary. To limit the influence of social desirability bias, participants were interviewed by members of the research team not directly involved in patient care (A.R.L, J.M.B., and V.V.). Team members used established strategies aimed at mitigating social desirability bias, such as indirect questioning and probing. 27 In-person interviews took place in varied settings to accommodate participants, including community housing, shelters, hospital or hospice, and outdoors. All interviews were audio recorded and transcribed verbatim by a member of the research team (A.R.L., J.M.B.). One participant consented for the interview but declined to be quoted directly. Another initially consented but was found to be incapable during the interview, and their data were excluded. Due to the unique circumstances of participants experiencing both homelessness and a life-threatening illness, providing every participant a transcript for review was not logistically feasible. The proposed benefits of member checking are contested, especially when participation is inconsistent. 28 For this reason, we did not conduct member checking. Interviews followed a guide developed collaboratively and modified iteratively by the full research team (all authors) (eMethods 2 in Supplement 1 ).

Data Analysis

Data analysis occurred alongside data collection. All transcripts were imported into NVivo, version 14 (Lumivero). Following a reflexive, iterative process informed by interpretative qualitative description, coding was guided by and adapted to the data. 22 , 23 Five members of the research team (A.R.L., J.B., D.S., N.D., and T.M.) began by individually coding 4 transcripts using an inductive approach, 22 , 23 and then met to compare and refine initial codes. Four additional transcripts were coded using the revised codes. Through this deliberative process, refined and emergent codes were grouped into subthemes and then major themes. The Figure illustrates this process for the major theme of relational care. All transcripts were recoded using this framework. Interpretive sufficiency was achieved through ongoing team discussions and iterative engagement with data. The research team (all authors) determined that additional interviews were unlikely to yield new insights or deepen interpretation. Final themes were collaboratively refined and agreed on.

Results

Table 1 presents demographic characteristics of the 14 participants. Ages ranged from 20 to 70 years. All but 2 participants were men, which is reflective of the PEACH patient population. 20 Malignant and nonmalignant terminal conditions were equally represented (ie, 7 patients in each). Most participants lived in a shelter or in community or social housing at referral and were referred to PEACH by physicians. Duration of contact with PEACH at the time of interview ranged from 3 to 69 months (mean, 18 months).

Six major themes were identified: life before PEACH, outreach and community care, medical needs, social needs, relational care, and constructive feedback. Table 2 , Table 3 , and Table 4 provide selected illustrative quotes; additional supplementary quotes are presented in eTables 1-3 in Supplement 1 .

Life Before PEACH

Although participants were not asked explicitly about their life before PEACH, nearly all volunteered this information. Within this broader theme, 4 subthemes emerged: hard life, substance use, previously encountered barriers, and stigma ( Table 2 ).

All participants described severe hardships before PEACH, including homelessness, incarceration, serious illness, bereavement, and trauma. For example, 1 participant stated “My wife got ALS [amyotrophic lateral sclerosis] about 5 years ago, and that’s it. Died. And after that I ended up homeless.” Many also endured long waits for housing, unsafe conditions, and limited social support.

Several participants had a history of substance use, often linked to trauma, health struggles, and marginalization. As 1 participant described, “There was 8 kids in my family, and me and my brother were the only ones my dad beat, and we both became addicts... That’s not a coincidence. That’s our trauma.”

Before PEACH, most participants encountered systemic health care barriers, including long waits, limited access to medications, and dismissive treatment. Some also felt stigmatized due to substance use, past incarceration, or housing status. One participant shared, “You’re frowned on, you know what I mean? Pretty much everywhere… because they look at [you] like, if you weren’t doing this, you wouldn’t be [in this situation].”

PEACH Patient Services

The themes outreach and community care, medical needs, social needs, and relational care reflect different aspects of the services provided by PEACH ( Table 3 ).

Outreach and Community Care

Analysis revealed 5 subthemes within the theme of outreach and community care: connecting with PEACH, ease of access, home care, care coordination, and collaboration. Participants highlighted a low-barrier referral process, often initiated by allied health professionals or case workers. The PEACH team frequently connected with participants and their inpatient care teams, which allowed for care to be transitioned immediately after discharge from the hospital. PEACH remained accessible, offering a direct line of communication for nearly any issue. As a participant described, “Every time I have the slightest problem, I call [the PEACH Health Navigator] right away. And she really fixes it or points me in the right direction.”

Participants also emphasized the value of receiving medical care in their community setting, addressing challenges related to mobility, disability, finances, and navigating health care spaces. One participant explained, “I’m in a [shelter] program. I don’t, like, really get around. It’s a big place. There is a lot of people here. But [PEACH], they go through all the red tape and come right to my room.”

Many also relied on PEACH to coordinate their care, managing appointments, arranging transportation, and collaborating with other health and social service organizations. As 1 participant said, “[PEACH does] everything that is cancer related. From setting up the appointment to dealing with the [oncologists], to getting the transportation, making sure people are coming with me, that I’m well supported, everything. And excellently!”

Medical Needs

Participants spoke to 5 subthemes within the theme of medical needs: pain and symptom management, primary care, medical supplies, mental health care, and harm reduction. As a palliative care team, pain and symptom management is central to PEACH’s work. Many participants felt PEACH addressed severe symptoms that had gone untreated due to systemic barriers and stigma. One participant shared, “If it wasn’t for them, I’d be nowhere near where I am… Well, because I was lying in the bed crying all day long because of the pain, and now, I can actually sit here and talk to you. Three to 4 months ago, I wouldn’t have been able to do that.” Beyond symptom management, participants described PEACH meeting other medical needs, often stepping into primary care roles and providing essential medical supplies to help manage serious medical conditions comfortably.

Several participants also emphasized the importance of embedded mental health care, which helped them overcome longstanding barriers to psychiatric support. As 1 participant shared, “There’s also the subsequent [psychological] fallout from the moment that you know you’re going to die, right? The mental, the everything. [PEACH] have taken care of everything.”

Finally, a few participants spoke indirectly to harm reduction, a core principle of PEACH’s care. Some credited PEACH with helping them use substances more safely or reduce substance use.

Social Needs

Participants frequently spoke to PEACH’s role in addressing their social needs. Four subthemes emerged: financial support, housing, food security, and connecting with loved ones.

PEACH addressed financial challenges by helping participants access disability benefits, medication coverage, and providing essential items. Many participants had struggled to find such support in the broader health care system: “[PEACH] came and helped me fill out the disability tax credit, which was good… I asked every [previous] doctor to [complete] it, and everyone said they were going to do it, and no one ever did it.”

Participants also emphasized PEACH’s role in helping them find safer, more stable housing, which often improved their overall well-being. One participant shared, “They’re currently helping me right now with my house… and right now as we speak, I’ve actually gotten 2 applications in for 2 apartments. And yeah, that’s through PEACH. PEACH has helped me out greatly on that. They got me through Toronto housing ahead of time and beautiful housing.”

While financial support and housing were most frequently mentioned, other participants received help accessing food or nutritional supplements. PEACH also supported participants in reconnecting with loved ones: “PEACH gave me hope. Additionally, my grandchildren are going to remember me you know. He’s only 2 months old, but he’s going to remember me.”

Relational Care

All participants commented on PEACH’s overall approach to care, which we refer to here as relational care. Three subthemes emerged within this overarching theme: compassionate approach, different kind of people, and wouldn’t be here without PEACH.

Participants described PEACH staff as more than just health care professionals; they were trusted individuals who made participants feel valued and supported:

The best thing that I found about the PEACH team is the compassion that they had. I believe that everybody that I dealt with truly had the ambition to help. And that was the best thing, was that they wanted to help. And you don’t find that everywhere. In hospitals, it’s the choice of doctors and nurses… Best thing, knowing that somebody gives a shit. That’s great.

Most participants felt this compassionate approach stood in stark contrast to their past experiences in the health care system. PEACH staff were seen as warm, approachable, and genuinely committed to patient-centered care:

Yeah, they are amazingly caring. I’m not used to this. I’ve worked with 4000 other people, and basically, you’re told to fuck off all day long… But these people, they come to my place, and I don’t know, they’re just so, so good. And I’m not used to that. Anytime I’ve walked into a walk-in clinic or anything like that, they’re just so, so impersonal. And with these people, it’s just like they’re caring!

Several participants also credited PEACH with saving their lives. As 1 participant stated, “I wouldn’t be here today if it wasn’t for PEACH. I’d be dead.”

Constructive Feedback

Three subthemes emerged within the broader theme of constructive feedback: gratitude, PEACH would be a good service for others, and areas for improvement ( Table 4 ). Participants were explicitly asked to offer critical feedback to help improve the program. Despite this, most shared only commendations. Many responded to questions about limitations with expressions of gratitude, such as “They’re doing a wonderful job… I wouldn’t change anything. Just give them [my] blessing, and [I’m] grateful for them, thankful for them.” Several also expressed a desire for more people in similar situations to have access to PEACH.

PEACH’s team-based model meant participants were sometimes engaged by multiple health care professionals, and a couple of participants expressed a desire to have a single, consistent doctor: “I mean to have a regular doctor look after your needs rather than different ones all of the time would be great.” Another concern included a lack of public awareness of PEACH in various settings across the homelessness sector.

Discussion

This qualitative study explored patient perspectives on a palliative care outreach intervention for adults experiencing homelessness. Participants described many positive factors across 4 domains: outreach and community care, medical needs, social needs, and relational care. Feedback was overwhelmingly positive, with many participants crediting the intervention with improving, and in some cases, saving their lives.

Only 1 prior study, a case report, has examined a palliative care intervention for people experiencing homelessness from the perspective of the participants. 17 Ours is the first study, to our knowledge, to evaluate patient perspectives on a palliative care outreach team. We had to overcome substantial challenges in conducting interviews in homes, shelters, and on the street. People experiencing homelessness face substantial barriers to traditional palliative care, 7 , 29 , 30 and participants emphasized PEACH’s accessibility, communication, and care coordination. While previous research suggests persons experiencing homelessness emphasize symptom management needs at the end of life, 7 , 30 our findings also underscored unmet primary care, medical supply, and psychiatric needs. One review identified only 1 palliative care intervention that directly addressed social needs for this population, primarily through hospice admission and family reconnection. 1 , 31 In contrast, participants in our study emphasized the value of income supplementation and food security, alongside stable housing and social connection, when facing advanced illness. Participants also spoke extensively about the PEACH team’s compassionate, empathetic, trauma-informed approach and accessible demeanor. This emphasis on compassion aligns with previous qualitative research on end-of-life perspectives among people experiencing homelessness. 30 , 32 In addition to considering accessibility, medical, and social needs, future palliative care outreach interventions should adopt care philosophies that are responsive to the unique needs of persons experiencing homelessness.

The results of our study offer foundational insight for developing palliative care outreach teams for equity-deserving populations in other jurisdictions. Further research evaluating such programs would strengthen the evidence base and support broader policy and funding decisions. Additional studies are needed to assess the effects of palliative care outreach on measurable health outcomes, such as symptom scores, functional performance, and hospitalization rates. Finally, as this is only the second study that we are aware of to examine end-of-life care interventions from the perspective of persons experiencing homelessness, this work underscores the need for continued research in this area. 1

Limitations

This study has limitations. There was an overrepresentation of men among participants; only 2 of 14 respondents were women. While this number is reflective of the overall PEACH patient population, women comprise nearly 50% of Canada’s homeless population. 33 Our recruitment aimed to obtain a sample reflective of the PEACH patient population, but future studies could consider alternative approaches to increase the representation of women. Results may also be influenced by the research team’s combination of purposive and convenience sampling. However, this approach was necessary given the unique challenges in reaching this population, including severe illness, housing instability, substance use, and mental health issues. Although the study aimed to elicit critical feedback, responses were overwhelmingly positive, limiting conclusions about weaknesses of the intervention and opportunities for improvement. Participants may have been concerned criticism would jeopardize their care, despite the mitigatory practices employed by the research team. Nonetheless, critical feedback gathered aligns with key themes in our findings and previous literature, including the importance of consistent communication, social support, and trusting relationships.

Conclusions

In this qualitative study of a palliative care outreach intervention from the perspective of adults experiencing homelessness, participants emphasized key aspects of the intervention, including compassionate, accessible care, and attention to unmet physical, psychological, and social needs. These findings can inform future outreach-based palliative care programs for these vulnerable members of society.

eMethods 1. Participant Consent Form

eMethods 2. Interview Guide

eTable 1. Supplementary Quotes – Life Before PEACH

eTable 2. Supplementary Quotes – PEACH Patient Services

eTable 3. Supplementary Quotes – Constructive Feedback

Data Sharing Statement

References

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Associated Data

Supplementary Materials

eMethods 1. Participant Consent Form

eMethods 2. Interview Guide

eTable 1. Supplementary Quotes – Life Before PEACH

eTable 2. Supplementary Quotes – PEACH Patient Services

eTable 3. Supplementary Quotes – Constructive Feedback

Data Sharing Statement