g. shelters, soup kitchens, syringe exchange programs, etc.) should be formally partnered with the end-of-life care system. Participants articulated how the trust developed between these agencies and homeless populations helped to mediate access to a range of other services (e.g., primary care, specialists, etc.) and could perform a similar function

in the context of end-of-life care. Furthermore, participants reported that these agencies, and especially trusted staff, were able to monitor changes in health status over time due to their sustained contact with this population and mediate access to health and end-of-life care services. For example: “We work together Inhibitors,research,lifescience,medical at three Inhibitors,research,lifescience,medical sites. Because many of our patients that we have [in the hospice] have been known to the other two sites, there’s kind of a family. In that way, we help each other and we communicate

with each other. As far as other facilities go, we use what’s out there in the community. Our patients may be known to some community health centers. (Nurse)” Participants felt that, where partnerships were weak or did not exist, they needed to be developed. Several participants also noted that third-party advocates (e.g., patient navigators) could play a role in Inhibitors,research,lifescience,medical acting as liaisons between community agencies and the end-of-life care system to strengthen these partnerships. For example: It would be helpful to have like individuals Inhibitors,research,lifescience,medical who serve as bridges between the [health and social services] systems. Usually, check details people don’t want a system. They want a person that they can call so, the doctor or the health care team in the hospital would prefer that there is a person that they can call to help them out rather than saying “These are the steps that you do.”

I think that people are the key to building bridges. (Physician) Strengthening training for end-of-life care professionals Participants reported that increased training was needed to strengthen the capacity of healthcare professionals to address the complex and diverse needs of homeless Inhibitors,research,lifescience,medical populations at end-of-life (e.g. pain and symptom management, substance use, etc.). Participants noted that, while they valued until the clinical expertise of healthcare professionals, clinicians often lacked experience in areas such as mental health and substance use that limited their effectiveness and openness to best practices. One participant remarked: “When you’re trained in your profession, you’re trained in a certain way. If harm reduction wasn’t in your training, you’re not going to know anything about it. How can you expect somebody to embrace that with open arms if they know nothing about it? (Harm Reduction Specialist)” Participants acknowledged that they needed to strengthen their training in these areas, as well as provide training opportunities for students.