Background: The homeless population is aging, with increasing proportions over age 50. People experiencing chronic homelessness, defined as prolonged or multiple homeless episodes with a disabling condition, have accelerated aging and high rates of mortality. Due to fragmented interactions with the health care system and social isolation, chronically homeless older adults are at high risk of not having their wishes for medical care documented or followed. Advance care planning (ACP) aims to elicit patients' medical wishes; yet, older homeless adults have low rates of ACP. Significant policy attention has focused on rehousing chronically homeless people into Permanent Supportive Housing (PSH). While PSH represents a unique setting to initiate ACP, there are no studies of ACP in PSH. Our team has created easy-to-use, evidenced-based ACP tools, such as an easy-to-read advance directive (AD) and a web-based educational program with video stories (PrepareForYourCare.org) to be used in group visits or with a one-on-one facilitator. However, these ACP interventions require adaptation for PSH settings. The objective of this proposal is to adapt, pilot, and demonstrate the feasibility of evidenced-based ACP interventions for a unique population (formerly chronically homeless older adults) in a novel setting (PSH).
Aims : We will adapt the easy-to-read AD (Aim 1), the group visit guide (Aim 2), and the one-on-one facilitator guide (Aim 3) to meet the needs of older (? 50 years of age) PSH residents. Then, we will pilot the adapted ACP interventions to assess the feasibility of delivering the ACP interventions in the PSH setting and obtain feedback on the intervention and processes.
(Aim 4). Methods:
In Aims 1 -3, we will conduct three focus groups for each Aim, with 6-10 older (? 50) PSH residents each. We will apply the Behavior Change Wheel (BCW) framework, which uses the Capability Opportunity Motivation Behavior (COM-B) model to understand targeted behaviors (i.e., ACP engagement) in context, the barriers to use of the ACP interventions, and strategies to overcome them. We will conduct thematic content analysis to determine needed adaptations to overcome these barriers and create additional material to meet PSH residents' needs. We will adapt both materials and processes based on this input.
In Aim 4, we will assess the feasibility of our recruitment procedures, our survey materials, and the group visit and facilitator interventions. We will assess satisfaction using validated questionnaires and obtain feedback about feasibility of the interventions and our study procedures in the PSH setting. A Community Advisory Board of key PSH leaders, residents and staff will work with the investigators to guide the study. Relevance to NIH and public health: The proposed project will develop ACP interventions for use in PSH, which we will test in a future R01-funded efficacy randomized trial. These interventions may reduce health disparities in ACP among formerly chronically homeless older adults.
The homeless population is aging, with an increasing proportion of individuals over age 50 who experience accelerated aging, high rates of mortality, and a high risk of not having their wishes honored at the end of life. The goal of this proposal is to adapt, pilot, and demonstrate the feasibility of evidenced-based advance care planning (ACP) interventions (i.e. an easy-to-read advance directive, a ACP group visit guide, and a ACP one- on-one facilitation guide) for a unique population of older adults living in Permanent Supportive Housing, the evidenced-base strategy to rehouse formerly chronically homeless adults. The proposed project will develop ACP interventions for use in Permanent Supportive Housing that we can test in a future R01-funded efficacy randomized trial and reduce health disparities in ACP among formerly chronically homeless older adults.
