Patient perspectives about a palliative care outreach intervention for adults experiencing homelessness are overwhelmingly positive, according to a qualitative, descriptive study of the Palliative Education and Care for the Homeless (PEACH) program in Toronto.

“While previous research suggests persons experiencing homelessness emphasize symptom management needs at the end of life, our findings also underscored unmet primary care, medical supply, and psychiatric needs,” wrote lead author Alexander R. Levesque, MD, of the Dalla Lana School of Public Health at the University of Toronto, and coauthors.

PEACH is a mobile-, street-, and shelter-based program with a team of palliative care physicians, psychiatrists, social workers, and nurses working with people experiencing homelessness across Toronto. The team collaborates with health and social service organizations to deliver palliative and psychiatric medical care, help secure housing, cover healthcare and medication gaps, and connect patients with publicly funded home healthcare supports. 

The data were published January 15 in JAMA Network Open. 

Semistructured Interviews 

The researchers recruited 14 program participants (12 males and two females) with terminal conditions, most of whom lived in shelters or social housing and had been referred to the program by physicians. Participants’ ages ranged between 20 and 70 years, and their duration of contact with PEACH ranged from 3 to 69 months (mean duration, 18 months) before the study. 

Using a descriptive, qualitative framework, the researchers conducted semistructured, one-on-one interviews to understand participants’ experiences. Interviews were conducted in person when possible or by phone between May 1, 2023, and November 30, 2024. The major themes that emerged were life before PEACH, outreach and community care, medical needs, social needs, relational care, and constructive feedback.

These interviews elicited mainly positive feedback about the program, “with many participants crediting the intervention with improving, and in some cases, saving their lives,” noted the authors, many of whom were somehow connected with the PEACH program.

“The thing that surprised us most was that everyone we interviewed kept coming back to the relational care part of PEACH,” Levesque told Medscape News Canada. “We thought that many clients would emphasize how the PEACH team helped with things like pain control, mental health needs, or housing, so it was surprising that most clients felt that the thing that really set the PEACH team apart was the compassionate, holistic approach they took to providing care.” 

“All participants described severe hardships before PEACH, including homelessness, incarceration, serious illness, bereavement, and trauma,” noted the authors. Before PEACH, most participants had systemic healthcare barriers, including long waits, limited access to medications, dismissive treatment, and stigmatization, they added.

Compassionate, Holistic Approach 

Participants described PEACH as having “a low-barrier referral process, often initiated by allied health professionals or case workers,” wrote the authors. They also highlighted the value of receiving medical care in their community setting, “addressing challenges related to mobility, disability, finances, and navigating healthcare spaces.”

In terms of medical needs, many participants felt PEACH addressed severe symptoms such as pain and psychiatric needs that had gone untreated because of systemic barriers and stigma. Harm reduction was also mentioned in terms of the encouragement of safer and reduced substance use.

Moreover, many participants stated that PEACH helped them with social needs such as financial questions, housing, and nutrition.

Finally, all participants mentioned relational care, referring to the program’s overall approach, said Levesque. “One of the main aspects of relational care highlighted by respondents was the PEACH program's compassionate, holistic approach. Respondents described the PEACH team as being warm, approachable, and caring, and contrasted that with their past experiences with the healthcare system where they often felt people were impersonal and not interested in forming trusting relationships with them.” 

One of the important findings was participants’ appreciation for having their psychosocial and palliative care needs met at the same time, said Levesque. “We think that this lesson could apply to any type of outreach team: being prepared to provide care and services outside what may be expected to meet the needs of this population,” he added. “We hope that our results will be informative to other current and future palliative care outreach teams, as well as outreach teams more broadly.” 

Voice and Visibility 

Commenting on the study for Medscape News Canada, Devora Keller, MD, MPH, director of clinical services and program operations for the National Health Care for the Homeless Council in Nashville, Tennessee, said the study “gives voice and visibility to a marginalized population that is often overlooked: individuals experiencing homelessness with serious and life-limiting illnesses.” Keller was not involved with the research. 

“It also raises awareness about the impact of a life-sustaining and dignity-enhancing care model that exists only in a few places in North America, while providing an intimate look into individuals' personal experiences in accessing services and navigating serious illness,” she added.

“I hope that having insight and understanding into how palliative care outreach teams directly enhance care for individuals experiencing homeless by hearing their reflections will encourage others to duplicate this model of care to support individuals within their own communities.” 

As a clinician who has worked closely with a street-outreach-based palliative care team in San Francisco, Keller said that the themes “resonated with my clinical experiences and the reflections of my own patients. The detailed accounts about the important role that these teams play in care navigation and care coordination underscore the immense challenges that people experiencing homelessness face in navigating critical illness and end-of-life care. The PEACH team's relationship-based, person-focused care and programmatic emphasis on both medical and psychosocial needs provides a critical template for programs considering developing a palliative care street outreach program.”

Funding for the study was not reported. Levesque reported receiving grants from the Canadian Institute of Health Research Canada Graduate Scholarship Master's program outside the submitted work. Keller reported no relevant financial relationships.

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.