Marcus is 53 years old. He has been sleeping in the same emergency shelter on the east side of town for nearly two years. Most nights, he gets a bed. Some nights, he does not. He ends up on a cot near the back wall or on the sidewalk outside when the shelter hits capacity. He has chronic obstructive pulmonary disease, COPD, and in the last several months, his cough has grown so bad that the men sleeping nearby ask him to move toward the door so they do not have to listen to it at 2:00 in the morning. He has lost 22 pounds. He gets winded walking to the bathroom. He knows something is seriously wrong.
Nobody called.
No one at the shelter has ever asked about his health. No doctor has offered a referral to palliative care. No social worker has sat down with him to find out what he would want if things got worse. He is invisible in a way that has nothing to do with being unseen and everything to do with being dismissed.
On a single night in January 2024, roughly 771,480 people in the United States were experiencing homelessness. Many of them, like Marcus, are managing serious, chronic, or terminal illnesses with zero formal support for comfort or end-of-life care. This article is about them. About who they are, what stands between them and the care they deserve, and what can actually change.
Dignity Is Not a Privilege
Dignity does not come with a lease. It is not earned by having a permanent address, a steady income, or a health insurance card. Every person, including every homeless person, deserves to be treated with respect and compassion when they are sick. That is not a political opinion. It is the ethical foundation on which every nurse, physician, and social worker’s training and license rests. Full stop.
What “Home” Means at the End of Life
Most of what we call end-of-life care was built around the concept of going home. Hospice care, specifically, is structured so that a care team comes to your home, manages your medications at home, and supports you in dying there, surrounded by the people you love. For a person sleeping in a tent, a car, or a shelter bunk, that entire model collapses before it can begin.
Research shows the mean age of death for homeless people ranges from 34 to 47 years, with age-adjusted death rates up to four times higher than the general population. That gap is not explained by lifestyle choices. It is explained by structural abandonment — a healthcare system that was not designed for people who have nowhere to go home to and has too often failed to adapt.
Who Is Most at Risk
Not all homeless people look the same. The common stereotype of a young man who chose the street misses the mark on reality. Older adults now make up roughly one in four of the homeless population in the United States, and that share is growing. By 2050, an estimated 95,000 older adults will be living without homes, confronting the high disease and mortality rates that come with aging on the margins.
Many homeless people live with what researchers call tri-morbidity: the convergence of a physical illness, a mental health condition, and a substance use disorder, all at the same time. Managing any single one of those conditions is hard. Managing all three without housing, without consistent medical care, and without a support system is, for most people, not manageable at all. The mortality data reflect this clearly; all-cause death rates for homeless people are significantly higher than for the general population, even when controlling for age.
Marcus is not an exception. He is the rule.
The Walls Between Homeless People and Good Care
There is no single reason why homeless people struggle to access palliative and hospice care. There are many, and they stack on top of each other. Together, they form a structure that most care systems were never designed to take apart.
Eight Barriers That Stand in the Way
Understanding these barriers is the first step toward doing something real about them:
No fixed address. Home-based care requires a home. A shelter bed, a tent, or a back seat does not qualify as a “home” under most palliative and hospice program models.
Lack of identification or documentation. Enrolling in Medicare or Medicaid, the programs that typically fund hospice care, requires a birth certificate, a Social Security card, and a photo ID. Many homeless people have none of those.
Distrust of healthcare systems. Years of discrimination, being turned away, being treated with contempt, or being discharged back to the street after a hospitalization keep many homeless people from seeking care until a crisis forces them into an emergency room.
Tri-morbidity. The combination of physical illness, mental health conditions, and substance use creates complex care needs that many facilities are neither staffed nor equipped to handle.
Zero-tolerance substance use policies. Some hospice facilities and residential care homes refuse admission to anyone who actively uses substances. A person who is terminally ill and struggling with addiction may be turned away from the only setting that could help them die with any degree of comfort.
Bureaucratic eligibility requirements. Hospice requires a physician to certify that a patient has six months or fewer to live. That certification requires an established medical relationship — something most homeless people lack.
Transportation and communication gaps. Without a working phone, a mailing address, bus fare, or a phone charger, follow-up care simply falls apart. Appointments are missed. Prescriptions go unfilled.
Fragmented continuity of care. Without a consistent care team assigned to a stable location, care plans break down. A homeless patient may tell their story to six different providers over the course of a year and receive six different responses.
How Palliative and Hospice Care Measure Up
Before looking at how each type of care handles these barriers, it helps to understand the difference between them. Palliative care focuses on comfort and quality of life for anyone living with a serious illness, at any stage, and alongside any other treatment. It does not require a terminal diagnosis. Hospice care is a specific type of palliative care for people who are terminally ill, have chosen to stop curative treatment, and have received a physician-certified prognosis of six months or fewer to live.
They are not the same, and that difference matters enormously for homeless patients.
How Palliative and Hospice Care Measure Up Against Common Barriers
Barrier
Palliative Care
Hospice Care
No fixed address
Can be delivered in clinics, shelters, or through street outreach programs
Requires a home setting; very limited flexibility without a fixed address
Lack of ID/documentation
More flexible in community-based programs that do not require insurance enrollment
Requires Medicare/Medicaid enrollment, which depends on having valid documentation
Distrust of the healthcare system
Can be offered in low-barrier, familiar settings such as shelters and day centers
Requires formal enrollment, a process many homeless people actively avoid
Tri-morbidity
Can run alongside treatment for all three conditions at the same time
Many residential facilities exclude people with active mental health or substance use needs
Zero-tolerance policies
Generally, not a barrier in outreach-based or shelter-based models
A significant barrier in most residential hospice settings
Eligibility requirements
No prognosis requirement; available to anyone with a serious illness
Requires a physician-certified prognosis of six months or fewer to live
Transportation and communication
Outreach-based models go to the patient; no travel required from the patient
Home delivery of care is impossible without a stable, reachable address
Continuity of care
Possible when a dedicated navigator is assigned; fragmented without one
Requires a consistent team linked to a fixed home location to function properly
The picture is clear. Palliative care, especially when delivered through outreach and shelter-based models, is far more adaptable for homeless patients than traditional hospice. That does not mean hospice has nothing to offer this population. It means hospice programs must seriously rethink how they operate if they genuinely intend to serve homeless people.
Four Ways Care Agencies Can Close the Gap
Closing this gap does not happen by accident, nor by waiting for someone else to lead. Hospice and palliative care agencies have both the clinical expertise and the ethical obligation to act. Here are four specific, evidence-supported ways to do it.
Go to Where People Are
Expecting a homeless person to come to you is not a care plan. It is an assumption that erases the reality of their daily life.
Street medicine programs, shelter-based care teams, and medical respite programs are the most direct tools for reaching people who cannot come to a clinic. Medical respite provides short-term residential care for homeless people who are too ill to recover on the street but not sick enough for a hospital stay. Some of these programs have begun integrating palliative and hospice services directly into their care models.
Think about Marcus again. What would change if a palliative care nurse came to his shelter on Wednesday afternoons? She could sit with him, assess his breathing, ask him what he is most afraid of, and connect him with a physician who could formally evaluate his COPD. He would not need to navigate the bus system, find a photo ID, or walk into a building he has never trusted. She would come to him.
The National Health Care for the Homeless Council maintains a searchable directory of Health Care for the Homeless grantees across the country. Many already provide integrated medical, behavioral, and social services that are natural partners for palliative care teams ready to extend their reach.
Hire and Fund a Healthcare Navigator
The paperwork alone can destroy a care plan before it gains any traction. Procuring identification, completing Medicaid enrollment, filing for benefits, coordinating with shelter staff, scheduling appointments, and making sure a patient actually shows up — none of that falls neatly under a clinician’s job description, and none of it happens automatically for someone who is homeless.
A dedicated healthcare navigator, typically a social worker or community health worker trained in both palliative care and homeless services, changes that equation.
One evaluation of a Canadian navigator program documented a single navigator completing more than 2,000 care activities in one year for homeless adults with serious illness. That included attending medical appointments alongside patients, helping complete advance directives, connecting people to shelter, managing medication refills, and being a consistent, trustworthy human presence in a system that often feels hostile. Two thousand activities. One person. One year. That investment also directly reduces costly emergency department visits and hospitalizations that result when no one is following up at all.
Train Every Staff Member in Trauma-Informed Care
Standard clinical communication does not consistently work with homeless patients. A directive tone, a rushed intake, a question about substance use asked without sensitivity — any of these can push a homeless person out the door permanently. The research on this is direct and consistent.
Trauma-informed care is a framework built on understanding that trauma is widespread, often undisclosed, and shapes how people respond to every healthcare encounter they have. Harm reduction is a related approach that meets people where they are with substance use, rather than demanding abstinence as a precondition for receiving care.
The PEACH program, Palliative Education and Care for the Homeless, developed in Canada, trains both clinical staff and shelter staff across four core areas: trauma-informed care, harm reduction, anti-oppression practice, and interprofessional teamwork. Studies show measurable improvements in staff confidence, communication quality, and palliative care delivery for homeless patients. One finding stands out: when physical symptoms were properly managed through harm reduction strategies, some terminally ill homeless patients voluntarily and gradually reduced their illicit drug use — not because they were told to, but because they felt safe enough to do so on their own terms.
That is what person-centered care actually looks like in practice.
Build Cross-Sector Partnerships That Actually Function
Healthcare alone cannot close this gap. Palliative and hospice care agencies need functioning, active relationships with homeless shelters, transitional housing programs, substance use treatment centers, social services departments, and mental health providers.
This does not mean a memorandum of understanding filed in a cabinet. It means regular case conferences, shared care plans, and people who actually pick up the phone when a colleague calls.
When the Center to Advance Palliative Care (CAPC) documented the case of a woman named Sheila, living in her late husband’s truck while receiving chemotherapy after losing her housing during treatment, it was a palliative care team working alongside a street outreach team that finally created a care plan that held from one week to the next. One phone call. One working relationship between two agencies. No single provider could have done that for her alone.
The collaboration was the care.
What You Can Do as an Ordinary Person
You do not need a medical license to make a difference here.
See the Person First
When you see someone who is homeless and visibly unwell, sitting outside a pharmacy, struggling to breathe near a bus stop, unable to stand without holding the wall, the easiest response is to look away. Society has conditioned people to read that as neutrality. It is not neutrality. It is a choice.
You do not have to diagnose anyone. You do not have to provide medical care. You can speak. You can ask, “Are you okay? Is there something you need?” You can treat a person like what they are: a human being who is suffering and who deserves to be acknowledged.
Marcus waited eleven months before a single shelter staff member stopped and said, “That cough sounds serious. Have you talked to a doctor?” Eleven months. One person who finally looked at him changed the course of events.
Know What Resources Exist Near You
Most communities have resources specifically designed to help homeless people access healthcare. Most ordinary people have no idea those resources exist.
The NHCHC’s Health Care for the Homeless grantee directory is searchable by state and available online at no cost. Local community health centers, free clinics, and medical respite programs often serve patients regardless of insurance status or documentation, and many can connect homeless individuals directly to palliative care services. Find out what exists in your city before you need that information. Write it down. Keep the number saved. If you work somewhere you regularly encounter homeless people — a grocery store, a library, a bus line, a church, a laundromat — that list may be the most practical and valuable thing you can give someone on any given day.
Support the Organizations That Fill the Gaps
Volunteer. Donate. Advocate. These are not abstract calls to “raise awareness.” They are concrete actions that directly fund care for people who have no other source of support.
Volunteering with a medical respite program, a street outreach team, or a Health Care for the Homeless clinic puts your time directly where the gap is. Financial donations fund navigators, outreach nurses, medications, and the shelter beds that make dignified care possible. Advocacy — writing to your city council, your state legislators, your federal representatives — about policies that fund homeless healthcare and medical respite creates systemic change that individual goodwill, no matter how sincere, cannot produce on its own.
Pick one. Start this week.
A Call to Action — For Everyone
This is not a crisis happening somewhere else. It is happening in every American city, in every state, in nearly every community large enough to have a shelter or a street corner where someone sleeps at night.
To palliative care and hospice agencies: The research has been accumulating for years, and it points in one direction. Homeless people are dying without comfort, without dignity, and without the care your agencies exist to provide. The barriers are real. They are also not insurmountable. Street outreach models work. Navigator programs work. Trauma-informed training works. Cross-sector partnerships work. What does not work is waiting for broader systemic reform before you change how your own agency operates. You have the clinical knowledge, the community standing, and in many cases, the funding flexibility to begin right now. Not at the next planning retreat. Not in the next fiscal year. Now.
To the general public: You are not powerless here. A homeless person near you may be quietly managing COPD, cancer, heart failure, or another serious illness with no one asking how they are doing or what they need. You cannot solve homelessness by yourself. You can see a person. You can ask. You can know your community’s resources and share them. You can vote for leaders who fund homeless healthcare, and you can support the organizations that show up every day in the gaps the system leaves behind.
Marcus deserved a palliative care nurse. He deserved a navigator. He deserved someone who walked into that shelter, sat down beside him, and said, “Let’s figure out what you need.”
Whether the next Marcus gets that care, or dies without it, is not entirely out of your hands.
Free Daily Symptom Tracker: Each headache, flare, or fatigue spike reveals a clue. This two-page Daily Symptom Tracker records sleep quality, food intake, triggers, severity, and effective relief methods—all in one place. Use it daily for 31 days and share the pages with your healthcare provider or health navigation expert. Together, you can move from guessing to addressing the root cause. Instructions on how to use the free daily symptom tracker and the free daily symptom tracker.
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