Aging Among the Homeless: Social Isolation, Function and Institutional Care

Investigator: Margot Kushel, MD
Sponsor: NIH National Institute on Aging

Location(s): United States


The proposed study will examine the association between social support, use of supportive services, and institutionalization in older homeless-experienced adults. The median age of people experiencing homelessness is 50. Despite the high prevalence of functional and cognitive impairment in this population, little is known about the use of long-term supportive services as a means to avoid institutional care. The results of this study will provide an evidence base to guide policies and programs to optimize housing and long-term services and supports to reduce acute care utilization and institutional care in older, homeless adults.

The long term goal of this proposal is to reduce the need for institutional care and identify optimal housing options in older adults with an experience of homelessness. The proposal seeks to renew AG041860, “Aging among the homeless: geriatric conditions, health and health care outcomes” also known as the Health Outcomes in People Experiencing Homelessness in Older Middle agE (HOPE HOME) study. HOPE HOME recruited and followed a cohort of 350 homeless adults aged 50 and older. Approximately half of all homeless adults are age 50 or older; the aging of the homeless population is expected to continue. In HOPE HOME, despite a median age of 58, we found a prevalence and severity of geriatric conditions, including functional, mobility and cognitive impairments, similar to that of community-living adults in their 70s. Participants had a high prevalence of behavioral health problems, social isolation, and narrow social networks. We found high rates of acute healthcare utilization and institutional care, including frequent stays in nursing homes. The majority of older adults will require assistance with activities of daily living (long-term services and support (LTSS)); most will receive this support from unpaid caregivers within their social network. Medicaid will pay for services but homeless older adults face numerous barriers to receiving LTSS, whether paid or unpaid. These barriers may increase their risk for costly and avoidable care and nursing home utilization. Therefore, we propose to extend the HOPE HOME study in order to examine 1) the prevalence of, and association between, perceived social isolation, social support, functional and cognitive impairments, and health care utilization; 2) the need for, use of, and barriers to home and community-based long-term services and supports; and 3) rates of and risk factors for nursing home placement and mortality. We propose to recruit an additional 80 participants to HOPE HOME to replace those who have died or been lost to follow-up, and to follow the cohort for three years, with six semi-annual visits for structured interviews and clinical assessments. We will recruit a sub-sample of study participants and a sample of key informants for in-depth qualitative interviews to understand the barriers to receiving LTSS, strategies to overcome those barriers, and optimal housing options that allow older homeless adults to avoid unnecessary health care utilization and institutional care. Study visits will take place at St. Mary's Center, a multiservice community-based center for older homeless adults. Trained research assistants, working under the supervision of study investigators, will administer clinical assessments and structured interviews to assess key variables. A Community Advisory Board, made up of community and policy leaders in homelessness and study participants, will work with the study team to guide study development and translate the findings into practice and policy changes. Study findings will contribute to the development of clinical, programmatic, and policy recommendations to optimize both housing outcomes and long-term services and supports for older adults who are, or recently have been, homeless.