April 4-6, 2024 • Hyatt Regency • Lexington, KY
Innovations in Health Communication
Innovations in Health Communication
Abstract: Adapting the Serious Illness Conversation Guide for Unhoused Older Adults
Introduction
Older adults experiencing homelessness (OAEH) age quickly and die earlier than their housed counterparts. The number of OAEH is rising, and they will face decisions about treating their serious illnesses while unhoused. These medical decisions are best guided by patients’ values, but many healthcare providers lack training to facilitate values-based discussions. Providers who have continuity with OAEH typically focus on securing resources, rather than exploring future care needs. The Serious Illness Conversation Guide (SICG) is an existing clinical tool that offers a script with question prompts, mapping the flow of a serious illness conversation. Core elements include health condition knowledge, prognosis, exploring values, worries, hopes, goals, and offering recommendations. Initially developed in oncology settings for nurse practitioners and physicians, it has not yet been adapted for OAEH. It also does not consider the needs of multidisciplinary or interprofessional providers, such as social workers, nurses, or other service providers who care for OAEH. We aimed to adapt the SICG for use with OAEH, social workers, nurses, and other care providers working with OAEH.
Methods
We conducted semi-structured interviews with service providers and cognitive interviews with OAEH using the SICG. Provider participants were nurses, social workers, or other providers working in homeless settings. OAEH were at least 50 years old and diagnosed with a serious illness. Interviews were conducted in shelters, transitional housing, a hospital, public spaces, and through Zoom. Interviews were recorded and transcribed verbatim. The research team identified common themes across transcripts while applying analytic note taking. We summarized transcripts from each participant group applying rapid qualitative analysis. For OAEH, data that referenced proposed adaptations or feedback about the SICG tool were grouped into two domains: “SICG interpretation” and “SICG Feedback”. For providers, we used domains from the Toolkit of Adaptation Approaches: “collaborative working”, “team”, “endorsement”, “materials”, “messages”, and “delivery”. Summaries were grouped into matrices to help visualize themes to inform adaptations. The adapted guide was then reviewed by expert palliative care clinicians for further refinement.
Results
The final sample included 11 OAEH (six White, five Black) with a mean age of 61, and 10 providers (eight White, 1 Black, 1 Latina) with an average 8.9 years of experience (average interview length 72.5 and 63.5 minutes, respectively). Adaptations included changing words and phrases to 1) increase transparency about the purpose and intent of the conversation, 2) promote OAEH autonomy and empowerment, 3) align with nurses’ and social workers’ scope of practice regarding facilitating diagnostic and prognostic awareness, and 4) be sensitive to the realities of fragmented healthcare. Responses also revealed training and implementation considerations for homeless service or program staff having serious illness conversations, and the practicalities of using a structured guide in these settings.
Conclusions
The adapted SICG is a promising clinical tool to aid in the delivery of serious illness conversations with OAEH. Future research should use this updated guide for implementation planning. Additional adaptations may be dependent on specific settings where the SICG will be delivered.
Older adults experiencing homelessness (OAEH) age quickly and die earlier than their housed counterparts. The number of OAEH is rising, and they will face decisions about treating their serious illnesses while unhoused. These medical decisions are best guided by patients’ values, but many healthcare providers lack training to facilitate values-based discussions. Providers who have continuity with OAEH typically focus on securing resources, rather than exploring future care needs. The Serious Illness Conversation Guide (SICG) is an existing clinical tool that offers a script with question prompts, mapping the flow of a serious illness conversation. Core elements include health condition knowledge, prognosis, exploring values, worries, hopes, goals, and offering recommendations. Initially developed in oncology settings for nurse practitioners and physicians, it has not yet been adapted for OAEH. It also does not consider the needs of multidisciplinary or interprofessional providers, such as social workers, nurses, or other service providers who care for OAEH. We aimed to adapt the SICG for use with OAEH, social workers, nurses, and other care providers working with OAEH.
Methods
We conducted semi-structured interviews with service providers and cognitive interviews with OAEH using the SICG. Provider participants were nurses, social workers, or other providers working in homeless settings. OAEH were at least 50 years old and diagnosed with a serious illness. Interviews were conducted in shelters, transitional housing, a hospital, public spaces, and through Zoom. Interviews were recorded and transcribed verbatim. The research team identified common themes across transcripts while applying analytic note taking. We summarized transcripts from each participant group applying rapid qualitative analysis. For OAEH, data that referenced proposed adaptations or feedback about the SICG tool were grouped into two domains: “SICG interpretation” and “SICG Feedback”. For providers, we used domains from the Toolkit of Adaptation Approaches: “collaborative working”, “team”, “endorsement”, “materials”, “messages”, and “delivery”. Summaries were grouped into matrices to help visualize themes to inform adaptations. The adapted guide was then reviewed by expert palliative care clinicians for further refinement.
Results
The final sample included 11 OAEH (six White, five Black) with a mean age of 61, and 10 providers (eight White, 1 Black, 1 Latina) with an average 8.9 years of experience (average interview length 72.5 and 63.5 minutes, respectively). Adaptations included changing words and phrases to 1) increase transparency about the purpose and intent of the conversation, 2) promote OAEH autonomy and empowerment, 3) align with nurses’ and social workers’ scope of practice regarding facilitating diagnostic and prognostic awareness, and 4) be sensitive to the realities of fragmented healthcare. Responses also revealed training and implementation considerations for homeless service or program staff having serious illness conversations, and the practicalities of using a structured guide in these settings.
Conclusions
The adapted SICG is a promising clinical tool to aid in the delivery of serious illness conversations with OAEH. Future research should use this updated guide for implementation planning. Additional adaptations may be dependent on specific settings where the SICG will be delivered.