Abstract
BACKGROUND: People experiencing homelessness access specialist palliative care late in their illness trajectory, if at all. There is also little evidence they receive generalist palliative care or are given opportunities to engage in Advance Care Planning. This qualitative study describes the central role of key workers in supporting access to healthcare in homeless communities and identifies implications for improving palliative care provision. METHODS: Qualitative data were collected via focus groups and individual interviews with staff working for a key provider of support and housing/accommodation for people experiencing homelessness in an urban area of Aotearoa New Zealand. RESULTS: The ability to provide palliative care for people experiencing homelessness is dependent upon supporting engagement with mainstream health services. It is here that we identified the key worker role as central due to the complex and expert work they undertake to facilitate healthcare access for their clients. As a result of the high burden of chronic conditions this community experiences, most of this work related to support managing serious conditions, as well as death and dying. Key workers often went 'above and beyond' to support their clients in engaging with mainstream health services, during outpatient appointments, hospital admissions and in emergency department settings. They felt clinicians in these settings did not recognise the knowledge they held about the person, or their skills in terms of providing trauma informed care. The inflexibility of current care provision, as well as people experiencing homelessness feeling stigmatised, and neither valued nor respected in these settings, also created barriers to receiving care. CONCLUSIONS: New models of palliative care are required which recognise the central role of non-health care key support staff and engage them more actively in supporting people experiencing homelessness when they interact with mainstream health services. Such models will need to be responsive to the nature and complexity of palliative care need in this population and facilitate support for people who typically do not see healthcare spaces as safe. The trusted relationships key workers have developed over time are crucial resources for identifying palliative care need and supporting access to palliative care for people experiencing homelessness.