Abstract 165: Challenges to Self-Management of Heart Failure Among Homeless Individuals: A Qualitative Study

Abstract

Background: Outpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved HF outcomes. Homelessness poses challenges to successful SM of many chronic diseases. Possessing a greater understanding of the barriers faced by homeless patients with HF, from the perspective of these patients, may lead to improved care of this vulnerable and under-studied population. Methods: We conducted open-ended, semi-structured interviews with HF patients with a history of current or prior homelessness within the past year. Data were analyzed using a grounded theory approach. The purpose of the interviews was to understand the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system. Results: Face-to-face interviews with 15 patients, 9 (60%) of whom were homeless at the time of interview, revealed a combination of influences on patients’ SM of HF. Major themes included instability and lack of ontological security, the need to make difficult tradeoffs, and the experience of stigma in the healthcare setting. While patients frequently reported instability as a reason for poor HF SM, instability itself proved to be a complex phenomenon with myriad manifestations. Patients reported that instability posed a barrier to the formation of medication, weight, and dietary routines, but also forced them to engage in short-term—rather than long-term—thinking surrounding HF as a chronic condition. Patients described having to make tradeoffs in HF SM; examples included choosing between attending HF clinic visits versus securing shelter, or prioritizing medications for comorbid conditions over those for HF. For some patients, homelessness served as a source of stigma, which resulted in perceived inequitable or inadequate care in both the inpatient and outpatient settings, and thus discouraged continued engagement with clinicians. Conclusion: Anticipatory guidance tailored toward the unique challenges faced by homeless individuals with HF may help to attenuate their difficulties with successful SM, but is likely insufficient. HF providers, too, must be made aware of the practical aspects of managing HF in the setting of homelessness. The vulnerability of this population necessitates creative approaches on the part of HF providers, including simplifying medication regimes and engaging in non-stigmatizing discourse.