Barriers and Delays to Healthcare at Time of Death: Qualitative Analysis of Los Angeles County Death Records of People Experiencing Homelessness

Background Human health and homelessness are incompatible with one another. People experiencing homelessness (PEH) experience extreme health and social inequities, including a significantly higher mortality rate and lower life expectancy compared to the general adult population. While many studies have attempted to identify the most common causes of death, no study to our knowledge has sought to contextualize these deaths using death records. The objective of this study was to conduct a qualitative analysis of the Los Angeles County medical examiner records of people experiencing homelessness from 2018 in order to identify modifiable barriers and delays in accessing health care services. Methods This study was a qualitative analysis of medical examiner records produced by the Los Angeles County Department of the Medical Examiner (DME). In 2019, the study’s senior author (EC) entered into a data use agreement with DME to provide records of deaths (n = 998) among people experiencing homelessness in 2018. The DME dataset was entered into a single file for coding using NVivo 12. Using thematic analysis as outlined by Braun and Clarke, the authors iteratively identified themes related to barriers and delays in healthcare to create a codebook. Results A strength of this study was its identification of barriers and delays to care themes (in italics) proximal to the deaths of PEH, an outcome that community and healthcare organizations aim to reduce. PEH are often suffering from extreme states of death due to advanced disease and have significant difficulty managing their health conditions , which manifests as medication non-adherence, missed dialysis, and a lack of preventative care. These factors, as well as disengagement and early termination of care (declining EMS services, AMA discharges) and a lack of a bystander response to PEH distress may have contributed to these deaths. Conclusions People experiencing homelessness experience many barriers and delays to care which may be linked to untimely deaths. This study highlights the importance of healthcare and community organizations serving PEH to foster social cohesion, understand reasons for PEH’s early termination and/or non-acceptance of care, and adopt equity-oriented care approaches, which aim to improve individuals’ ability to engage in outpatient services and treatment.