Integrating Psychiatry into a Community Based Palliative Care Team for People Experiencing Homelessness: A Descriptive Retrospective Cohort Study of the PEACH Psychiatry Program Model

Integrating Psychiatry into a Community Based Palliative Care Team for People Experiencing Homelessness: A Descriptive Retrospective Cohort Study of the PEACH Psychiatry Program Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Integrating Psychiatry into a Community Based Palliative Care Team for People Experiencing Homelessness: A Descriptive Retrospective Cohort Study of the PEACH Psychiatry Program Model Ovini Thomas, Jude Sanon, Lauren Thomson, Naheed Dosani, Daniel Rosenbaum, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7302203/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Jan, 2026 Read the published version in BMC Palliative Care → Version 1 posted 10 You are reading this latest preprint version Abstract Background People experiencing homelessness have higher morbidity rates and lower life expectancy than the general population. Additionally, there is a high prevalence of mental illness and substance use disorders within this group, which compounds their health issues and adds complexity to providing palliative care. The Palliative Education and Care for the Homeless (PEACH) program in Toronto provides palliative care to this population, and includes an integrated psychiatry service to support clients with mental illness. The aim of this paper is to describe a novel model of integrated psychiatric care and palliative care for structurally vulnerable people living with life-threatening illness and complex mental health needs. Methods We conducted a cross-sectional retrospective cohort study, collecting data from all patients referred to the PEACH psychiatry service in Toronto, Ontario, Canada from 2019 to 2023. The study included patients currently followed by PEACH Psychiatry, those deceased or discharged, and those referred but not assessed. Descriptive statistics were used to analyze the data. Results Out of 62 clients referred to PEACH psychiatry, 48 were included in the analysis. The majority were male (77.1%) and were aged 50–70 (68.7%). Referrals were primarily for psychiatric symptom management (45.8%) and support around coping with life-threatening illness (22.9%). Half of the clients had two or more psychiatric diagnoses, with depressive disorders, substance use disorder, and psychotic disorders being most common. Substance use disorder was the most common diagnostic impression post-assessment by psychiatry (25%). Therapies provided included medication management, psychotherapy, and diagnostic clarification. Conclusions This study outlines a model of integrated psychiatric care within a community-based palliative team serving structurally vulnerable populations. This kind of integrated care represents an important service to improve delivery of both palliative care and psychiatric support for structurally vulnerable populations. Palliative care mental illness psychiatry care homelessness structural vulnerabilities integrated care end of life care Background Individuals facing homelessness experience higher morbidity rates and have a markedly lower life expectancy compared to the general population. These disparities are largely due to structural vulnerabilities including gaps in service access, mistrust of the healthcare system, provider bias, and challenges receiving appropriate care ( 1 – 4 ). Additionally, the prevalence of mental health and substance use disorders (SUDs) are disproportionately high among this population, compounding their health issues ( 2 , 5 , 6 ). Individuals with a life threatening illness and severe and persistent mental illness (SPMI) ( 7 ) face additional barriers, including stigma, social isolation, and difficulties with information processing and communication. These challenges hinder their access to appropriate advance care planning and palliative/end-of-life care ( 8 – 12 ). People with SPMI have higher mortality, are less likely to receive treatment after a cancer diagnosis, and are less likely to receive opioid analgesia in the last months of life ( 13 , 14 ). Previous literature has described the challenges of providing end of life care for people with SPMI as well as SUDs ( 15 ), with a common issue being the lack of coordinated care between mental health clinicians, primary care and palliative care providers. Services are often ‘siloed’, which can prevent good collaborative care between psychiatric and palliative care providers. Furthermore, literature exploring how best to provide physical and mental health care to people living with mental illness suggests that integrating these services reduces barriers to care; however, this is unfortunately the exception rather than the norm for providing care to people with SPMI ( 16 – 21 ). Despite broad recognition of these challenges, there is a lack of literature that adequately describes or evaluates models of care for people living with life threatening illness, mental illness, and SUDs. This "tri-morbidity" - along with the added barrier of homelessness - presents unique obstacles in delivering high-quality palliative care, and the social and health inequities these individuals face often exacerbate their psychological distress in the face of terminal illness ( 5 ). Palliative Education and Care for the Homeless (PEACH) is a community-based outreach palliative care program, established in 2014, that provides palliative care to individuals facing structural vulnerabilities through a harm reduction and trauma informed approach in Toronto, Ontario, Canada. PEACH is housed within Toronto’s Inner City Health Associates, a homeless health services organization, and is staffed by palliative care physicians, a virtual nurse coordinator, a health navigator, a dedicated outreach nurse, and a peer worker. The team collaborates closely with publicly funded home care providers (e.g., PSWs, nurses, and other allied health workers). A retrospective chart review of PEACH indicated that 41.3% of clients referred to the program between 2014 and 2017 had at least one documented mental health diagnosis, and 41.3% reported using one substance ( 2 ). These clients have complex psychosocial needs that are not always addressed by mainstream care models, and they face significant barriers to accessing care due to stigma, discrimination, and mobility challenges. Recognizing the barriers faced by clients with mental illness, the psychiatry arm of PEACH was introduced in 2019. In this paper we describe the novel, integrated model of care that addresses both palliative and psychiatric care needs for structurally vulnerable clients in Toronto, Ontario, Canada living with a terminal illness. Key objectives of this study include describing the cohort of clients served, reasons for referral, and interventions provided by the service. We hope that this description of the PEACH psychiatry service will offer insight for other palliative care programs and improve access to high-quality palliative care and psychiatric care for structurally vulnerable populations. Methods Study Population This retrospective cohort study included all patients who were referred to and received care from the PEACH psychiatry team in Toronto, Ontario, Canada from January 2019 to May 2023. The study population included those who are currently followed by the PEACH psychiatry team, those who are now deceased or have been discharged, and those who were referred but never assessed. Setting: The PEACH Psychiatry Service The PEACH integrated psychiatry service was introduced in 2019. This initiative sought to address the complex psychosocial needs of clients with tri-morbidity by offering integrated, mobile psychiatric care for interested patients. PEACH also provides collaborative care with mainstream psychiatry services like Assertive Community Treatment (ACT) teams; however, an integrated model of care was piloted to improve access to psychiatric care for those who have not been connected with a psychiatrist or other mental health supports. The psychiatry service is funded through the Inner City Health Associates, the same organization that provides funding for PEACH, and it offers one day per week of outreach by a psychiatrist along with senior psychiatry resident physicians. The service provides direct patient care, informal consultations, and mentorship to PEACH palliative care clinicians. Additionally, the team is available by phone and by email beyond scheduled outreach, ensuring continuity of care. Because PEACH is a mobile palliative care service (i.e., there is no dedicated clinical space), the PEACH psychiatry arm cannot be described as “co-located”. However, the psychiatry service is integrated in several other ways, including a shared Electronic Medical Record; attendance at monthly team operations meeting; inclusion in daily email communications from palliative care clinicians about their clinical encounters; and facilitation of monthly rounds with allied health members of the PEACH team focused on patients followed by the psychiatry service. PEACH psychiatry also provides liaison services (i.e., connection with hospital or hospice staff, patient visits at these care settings, and participation in interdisciplinary case conferences). In these ways, PEACH psychiatry meets many of the nine structural and organizational factors for good integrated care for people with mental health problems as identified via mapping review by (16). Because PEACH is a mobile palliative care service, a provider experienced with outreach-based community psychiatry was sought from the outset. The following skills and experience were also sought: comfort working with patients with SPMI and those who use drugs; experience with medical psychiatry, including specifically the psychotherapeutic care of patients facing advanced disease; and comfort working in a multidisciplinary team. The first psychiatrist who occupied the PEACH psychiatry role (DR) had completed specialized training in both Assertive Community Treatment psychiatry in the inner city setting, as well as in psychosocial oncology and palliative care, including formal certification in Managing Cancer and Living Meaningfully (CALM) Therapy, a brief, individual psychotherapy developed to relieve distress and improve quality of life among individuals facing advanced cancer (22). In some ways, the PEACH psychiatry service reflects a blending of these worlds (i.e., outreach-based psychiatric care for patients with SPMI and structural vulnerabilities together with psychotherapeutic care of patients with advanced disease). Cohort description at time of initial palliative care consultation Descriptive statistics such as age, gender, palliative performance status (PPS), palliative care diagnosis, housing status, previous psychiatric diagnoses and substance use history were collected retrospectively from the initial palliative care consultation. At initial palliative care consultation clients discuss their code status with the physician (i.e. “full resuscitation” vs “Do not resuscitate”); this was also collected at the time of initial palliative care consultation from the electronic medical record. Description of psychiatric services provided Information on the reason for referral to psychiatry services and time to initial psychiatric consultation were collected retrospectively at the time of initial psychiatry consultation. Measures including the length of the therapeutic relationship with the psychiatry team, diagnostic impression, visit type (virtual vs outreach), therapies offered, and reason for discontinuing services were collected retrospectively from the time of psychiatric consultation. Data collection and analysis All data were collected retrospectively from the electronic medical record. Descriptive statistics were used to describe the cohort, and for confidentiality we have not reported any small cell sizes (N < 3). Data are reported in frequency along with percentage of the cohort. Data were verified by 3 separate members of the team for accuracy. Research ethics approval was obtained from the St.Michael’s Hospital Research Ethics Board (REB#23 − 004). Results Demographics From January 2019 to May 2023, a total of 62 clients were referred to the PEACH Psychiatry team. Thirteen clients were excluded from the study as they were not formally seen by the psychiatry team, or had declined palliative care services. Among the 48 clients included in this dataset, the majority identified as male (77.1%), were aged 50 to 70 (68.7%) and resided in subsidized housing (43.7%) or shelter (31.2%) at time of referral to psychiatry. See Table 1 for details. Referral information Patients were primarily referred for assistance with psychiatric symptom management (45.8%), while many others were referred for support around coping with a life-threatening illness (22.9%). Many clients were referred to psychiatry within 1 week of palliative care consultation (31.3%); however, a majority of clients were referred 12 weeks or longer after initial involvement with the palliative care team (39.6%). Clients were typically seen by the psychiatry service within 1-4 weeks (58.3%) of referral. Fifty percent of the clients had two or more previous psychiatric diagnoses; depressive, substance use, and psychotic disorders were the most common prior diagnoses. Most clients had a substance use disorder of 1 or more substances (55.1%). Clients referred to psychiatry typically had a Palliative Performance Scale score of >60% (67.3%), and the majority had malignancy as a primary palliative diagnosis (61.2%). See Table 2 for details. Psychiatry therapeutic relationship The majority of clients referred to psychiatry were seen 2 - 4 times (41.7%); however, 11 clients were seen over 10 times (22.9%). Most clients (68.7%) were seen exclusively by in-person community visits, and 35.4% of clients were followed for over twelve months. Therapies/services provided by the psychiatric team The most common diagnostic impression after psychiatric involvement was substance use disorder (25%) followed by an equal split between delirium/neurocognitive disorders (16.6%), mood disorders (16.6%), and 16.6% of patients with either normative distress or with an unclear diagnostic picture. The therapies provided by the psychiatry team included psychotropic medication modification/initiation and psychotherapy (41.7%), psychotherapy alone (22.9%), supportive counselling (14.6%) and diagnostic clarification (12.5%). Four clients (8.3%) had limited assessment and did not have any therapies provided. Death was the most common reason for discontinuing psychiatry services (37.5%). Nine clients (18.8%) were seen for a one time consultation. Otherwise, the psychiatric relationship remains ongoing for 18 clients (36.7%). Discussion Key Findings This study describes a novel model of integrated psychiatric care for a community-based palliative care team that serves structurally vulnerable populations. Most clients are seen in an exclusively outreach model and are offered both psychotherapy and psychotropic medication management. Only one client declined further services after initial psychiatric consultation; for most clients, services were only discontinued after they were transferred to hospice or died. Clients were referred quickly, most within 1 week, after assessment by a palliative care physician, and most clients received services for 2–4 visits. Some clients had longitudinal follow-up over 12 months, emphasizing the importance of early referrals to maximize the impact of psychiatric interventions in palliative care. Our results suggest that the role of psychiatry in palliative care for structurally vulnerable populations has a broad scope, ranging from diagnostic clarification, treatment recommendations, ongoing support and psychotherapy, informal support for the care team, liaison with inpatient providers, and one-off consultation to aid with capacity assessment. This integrated model allows for clients living with mental illness and those without mental illness who need psychosocial support to have access to both psychiatric care and symptom management when living with a life threatening illness. What this study adds Previous literature has highlighted that collaborations between psychiatry and palliative care can be challenging to achieve through mainstream services ( 15 – 20 ). This study describes a model that takes a unique approach of integrating community based psychiatry with community based palliative care, creating a low barrier for referral for structurally vulnerable clients to receive psychiatric services. Previous studies have shown that integrated psychiatry and physical health services can lead to improved vaccination rates and chronic disease screening for people living with mental illness ( 16 ). However, no previous studies have described a model of integrated psychiatry and palliative care. This study underlines the importance of integration as a method of providing collaborative care for those living with life threatening disease and mental illness. It also highlights the potential of a model to provide care in the community with a patient centered focus that reduces barriers to accessing palliative care for people living with mental illness. Strengths and Weaknesses/ Limitations This study’s strength is that it is the first to our knowledge to describe a model of integrated psychiatric and community based palliative care for structurally vulnerable people. The limitations of the study include the lack of healthcare utilization data for this cohort. Additionally, the study's quantitative nature leaves gaps in understanding the qualitative impact on patients and providers. Finally, this study cannot make any conclusions about the impact of the PEACH psychiatry service, including its acceptability, given that the data are descriptive and do not include outcomes or patient perspectives. Because PEACH psychiatry represents a model of integrated care, another limitation of this study is that we have not described patients followed by PEACH that receive psychiatric care from other community psychiatry teams. This is often the case for patients with SPMI who may have close relationships with, e.g., Assertive Community Treatment or similar teams. In an effort to enhance access to both mental health and palliative care for patients with SPMI, there may be a tension between prioritizing existing relationships – which in some cases are deep and longstanding – and the virtues of integrated mental health and palliative care (e.g., shared information systems, co-location, etc.). Indeed, depending on the needs of the patient, a more traditional community psychiatry team may be best suited to provide mental health care in collaboration with a separate community palliative care team. This might be the case, for example, if there is a need for psychiatric case management, supervised medication administration, or mandatory outpatient treatment. Next Steps A growing network of programs in Canada’s major cities provides palliative care to individuals who are precariously housed. We hope the PEACH psychiatry model can inspire the integration of psychiatric care into community-based palliative care programs for structurally vulnerable populations. Future studies should evaluate how integrated models of palliative and psychiatric care impact healthcare utilization and patient outcome measures. Qualitative studies are also needed to provide deeper insights into the experiences of both patients and providers within these integrated care frameworks. Finally, expanding education and training in this subspecialized area of psychiatry is crucial to equip professionals with the skills needed to effectively engage with and support this vulnerable population. Conclusion This study describes a novel integrated psychiatry service within a community-based palliative care program for structurally vulnerable populations. The PEACH psychiatry team provides an innovative approach to care by addressing unique challenges of caring for structurally vulnerable populations. Abbreviations SPMI - Severe and Persistent Mental Illness PEACH - Palliative Education and Care for the Homeless Declarations Research Ethics Board approval status: Approved by the Unity Health Toronto Research Ethics Board (REB#23-004), research conducted in accordance to the Health Canada Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans Consent for publication: Not applicable Consent to Participate: As this was a retrospective chart review consent was no obtained from participants and data was anonymized Availability of data and Materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing Interests: OT, JS, LT, DR, TM and ND do not have any competing interests to declare. Funding sources: None, self-funded Author Contributions: Author Contributions OT (Toronto, Canada)– Primary author, Project coordinator contributed to data analysis and manuscript writing. JS (Toronto, Canada) – Second author,; involved in data analysis and manuscript writing. LT (MD, FRCPC) (Toronto, Canada) –; co-author. ND (MSC, MD, CCFP(PC), BSc) (Toronto, Canada) – Founder and Lead of PEACH; contributed to the study design and, co-author. DR (MD, FRCPC) (Toronto, Canada) – Lead psychiatrist on the PEACH psychiatry team; co-Principal Investigator; contributed to the conceptualization of the study; co-author. TM (MD, CCFP(PC) (Toronto, Canada) – PEACH palliative care physician, PEACH Research Lead; Co- Principal Investigator, contributed to the conceptualization of the study, co-author References Buchanan N, Dosani N, Bond A, et al. Palliative Education and Care for the Homeless (PEACH): A Model of Outreach Palliative Care for Structurally Vulnerable Populations. Healthc Q . 2023; 26(1):24-30. doi:10.12927/hcq.2023.27055 Schneider E, Dosani N. Retrospective study of a Toronto-based palliative care program for individuals experiencing homelessness. Journal of Palliative Medicine. 2021 ; 24(8):1232-5. Hudson BF, Flemming K, Shulman C, Candy B. Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research. BMC Palliative care. 2016; 15:1-8. Klop HT, De Veer AJ, Van Dongen SI, Francke AL, Rietjens JA, Onwuteaka-Philipsen BD. Palliative care for homeless people: a systematic review of the concerns, care needs and preferences, and the barriers and facilitators for providing palliative care. BMC palliative care. 2018; 17:1-6. Stringfellow EJ, Kim TW, Pollio DE, Kertesz SG. Primary care provider experience and social support among homeless-experienced persons with tri-morbidity. Addiction Science & Clinical Practice. 2015; 10:1-2. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS medicine. 2008; 5(12):e225. Zumstein N, Riese F. Defining severe and persistent mental illness—a pragmatic utility concept analysis. Frontiers in psychiatry. 2020; 11: 648. Foti ME. " Do It Your Way": A Demonstration Project on End-of-Life Care for Persons with Serious Mental Illness. Journal of Palliative Medicine. 2003; 6(4):661-9. Huang HK, Wang YW, Hsieh JG, Hsieh CJ. Disparity of end-of-life care in cancer patients with and without schizophrenia: a nationwide population-based cohort study. Schizophrenia research. 2018; 195:434-40. Woods A, Willison K, Kington C, Gavin A. Palliative care for people with severe persistent mental illness: a review of the literature. The Canadian Journal of Psychiatry. 2008; 53(11):725-36. Chochinov HM, Martens PJ, Prior HJ, Kredentser MS. Comparative health care use patterns of people with schizophrenia near the end of life: a population-based study in Manitoba, Canada. Schizophrenia research. 2012; 141(2-3):241-6. Hinrichs KL, Woolverton CB, Meyerson JL. Help me understand: providing palliative care to individuals with serious mental illness. American Journal of Hospice and Palliative Medicine. 2022; 39(2):250-7. Donald EE, Stajduhar KI. A scoping review of palliative care for persons with severe persistent mental illness. Palliative & supportive care. 2019;17(4):479-87. Masel EK, Antunes B, Schulz-Quach C. Palliative care in severe mental illnesses. BMC Palliative Care. 2023; 22(1):31. Marti, L., Hünerwadel, E., Hut, B. et al. Characteristics and clinical challenges in patients with substance use disorder in palliative care—experience from a tertiary center in a high-income country. BMC Palliat Care. 2024; 23(28). 2024. https://doi.org/10.1186/s12904-024-01366-x Rodgers M, Dalton J, Harden M, Street A, Parker G, Eastwood A. Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness: A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations. Int J Integr Care. 2018; 18(1):9. doi:10.5334/ijic.2605 Bradford DW, Cunningham NT, Slubicki MN, et al. An evidence synthesis of care models to improve general medical outcomes for individuals with serious mental illness: a systematic review. J Clin Psychiatry. 2013; 74(8):e754-e764. doi:10.4088/JCP.12r07666 McNamara B, Same A, Rosenwax L, Kelly B. Palliative care for people with schizophrenia: a qualitative study of an under-serviced group in need. BMC Palliat Care 2018; 17(53). Riley, K, Hupcey, JE, Kowalchik, K. Palliative Care in Severe and Persistent Mental Illness: A Systematic Review. Journal of Hospice & Palliative Nursing. 2022; 24(3):p E88-E93 | DOI: 10.1097/NJH.0000000000000855 Bloomer, M & O'Brien AP. Palliative care for the person with a serious mental illness: The need for a partnership approach to care in Australia, Progress in Palliative Care. 2013; 21(1), 27-31, DOI: 10.1179/1743291X12Y.0000000033 Ward G, Holliday N, Coad J. Barriers to palliative care for people with severe mental illness: exploring the views of clinical staff. European Journal of Palliative Care. 2018; 25(1). Rodin G, Hales S. Managing cancer and living meaningfully: an evidence-based intervention for cancer patients and their caregivers. Oxford University Press. 2021 Apr 27. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files IntegratingPsychiatryintoaCommunityBasedPalliativeCareTeamforPeopleExperiencingHomelessnessADescriptiveRetrospectiveCohortStudyofthePEACHPsychiatryProgramModelSupplementaryTables.docx Cite Share Download PDF Status: Published Journal Publication published 21 Jan, 2026 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 10 Oct, 2025 Reviews received at journal 07 Oct, 2025 Reviewers agreed at journal 05 Oct, 2025 Reviews received at journal 04 Sep, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 14 Aug, 2025 Editor invited by journal 08 Aug, 2025 Editor assigned by journal 07 Aug, 2025 Submission checks completed at journal 07 Aug, 2025 First submitted to journal 05 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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These disparities are largely due to structural vulnerabilities including gaps in service access, mistrust of the healthcare system, provider bias, and challenges receiving appropriate care (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, the prevalence of mental health and substance use disorders (SUDs) are disproportionately high among this population, compounding their health issues (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Individuals with a life threatening illness and severe and persistent mental illness (SPMI) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) face additional barriers, including stigma, social isolation, and difficulties with information processing and communication. These challenges hinder their access to appropriate advance care planning and palliative/end-of-life care (\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). People with SPMI have higher mortality, are less likely to receive treatment after a cancer diagnosis, and are less likely to receive opioid analgesia in the last months of life (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrevious literature has described the challenges of providing end of life care for people with SPMI as well as SUDs (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), with a common issue being the lack of coordinated care between mental health clinicians, primary care and palliative care providers. Services are often \u0026lsquo;siloed\u0026rsquo;, which can prevent good collaborative care between psychiatric and palliative care providers. Furthermore, literature exploring how best to provide physical and mental health care to people living with mental illness suggests that integrating these services reduces barriers to care; however, this is unfortunately the exception rather than the norm for providing care to people with SPMI (\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite broad recognition of these challenges, there is a lack of literature that adequately describes or evaluates models of care for people living with life threatening illness, mental illness, and SUDs. This \"tri-morbidity\" - along with the added barrier of homelessness - presents unique obstacles in delivering high-quality palliative care, and the social and health inequities these individuals face often exacerbate their psychological distress in the face of terminal illness (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Palliative Education and Care for the Homeless (PEACH) is a community-based outreach palliative care program, established in 2014, that provides palliative care to individuals facing structural vulnerabilities through a harm reduction and trauma informed approach in Toronto, Ontario, Canada. PEACH is housed within Toronto\u0026rsquo;s Inner City Health Associates, a homeless health services organization, and is staffed by palliative care physicians, a virtual nurse coordinator, a health navigator, a dedicated outreach nurse, and a peer worker. The team collaborates closely with publicly funded home care providers (e.g., PSWs, nurses, and other allied health workers).\u003c/p\u003e\u003cp\u003eA retrospective chart review of PEACH indicated that 41.3% of clients referred to the program between 2014 and 2017 had at least one documented mental health diagnosis, and 41.3% reported using one substance (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These clients have complex psychosocial needs that are not always addressed by mainstream care models, and they face significant barriers to accessing care due to stigma, discrimination, and mobility challenges. Recognizing the barriers faced by clients with mental illness, the psychiatry arm of PEACH was introduced in 2019.\u003c/p\u003e\u003cp\u003eIn this paper we describe the novel, integrated model of care that addresses both palliative and psychiatric care needs for structurally vulnerable clients in Toronto, Ontario, Canada living with a terminal illness. Key objectives of this study include describing the cohort of clients served, reasons for referral, and interventions provided by the service. We hope that this description of the PEACH psychiatry service will offer insight for other palliative care programs and improve access to high-quality palliative care and psychiatric care for structurally vulnerable populations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eStudy Population\u003c/h2\u003e\n \u003cp\u003eThis retrospective cohort study included all patients who were referred to and received care from the PEACH psychiatry team in Toronto, Ontario, Canada from January 2019 to May 2023. The study population included those who are currently followed by the PEACH psychiatry team, those who are now deceased or have been discharged, and those who were referred but never assessed.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSetting: The PEACH Psychiatry Service\u003c/h3\u003e\n\u003cp\u003eThe PEACH integrated psychiatry service was introduced in 2019. This initiative sought to address the complex psychosocial needs of clients with tri-morbidity by offering integrated, mobile psychiatric care for interested patients. PEACH also provides collaborative care with mainstream psychiatry services like Assertive Community Treatment (ACT) teams; however, an integrated model of care was piloted to improve access to psychiatric care for those who have not been connected with a psychiatrist or other mental health supports. The psychiatry service is funded through the Inner City Health Associates, the same organization that provides funding for PEACH, and it offers one day per week of outreach by a psychiatrist along with senior psychiatry resident physicians.\u003c/p\u003e\n\u003cp\u003eThe service provides direct patient care, informal consultations, and mentorship to PEACH palliative care clinicians. Additionally, the team is available by phone and by email beyond scheduled outreach, ensuring continuity of care. Because PEACH is a mobile palliative care service (i.e., there is no dedicated clinical space), the PEACH psychiatry arm cannot be described as “co-located”. However, the psychiatry service is integrated in several other ways, including a shared Electronic Medical Record; attendance at monthly team operations meeting; inclusion in daily email communications from palliative care clinicians about their clinical encounters; and facilitation of monthly rounds with allied health members of the PEACH team focused on patients followed by the psychiatry service. PEACH psychiatry also provides liaison services (i.e., connection with hospital or hospice staff, patient visits at these care settings, and participation in interdisciplinary case conferences). In these ways, PEACH psychiatry meets many of the nine structural and organizational factors for good integrated care for people with mental health problems as identified via mapping review by (16).\u003c/p\u003e\n\u003cp\u003eBecause PEACH is a mobile palliative care service, a provider experienced with outreach-based community psychiatry was sought from the outset. The following skills and experience were also sought: comfort working with patients with SPMI and those who use drugs; experience with medical psychiatry, including specifically the psychotherapeutic care of patients facing advanced disease; and comfort working in a multidisciplinary team. The first psychiatrist who occupied the PEACH psychiatry role (DR) had completed specialized training in both Assertive Community Treatment psychiatry in the inner city setting, as well as in psychosocial oncology and palliative care, including formal certification in Managing Cancer and Living Meaningfully (CALM) Therapy, a brief, individual psychotherapy developed to relieve distress and improve quality of life among individuals facing advanced cancer (22). In some ways, the PEACH psychiatry service reflects a blending of these worlds (i.e., outreach-based psychiatric care for patients with SPMI and structural vulnerabilities together with psychotherapeutic care of patients with advanced disease).\u003c/p\u003e\n\u003ch3\u003eCohort description at time of initial palliative care consultation\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics such as age, gender, palliative performance status (PPS), palliative care diagnosis, housing status, previous psychiatric diagnoses and substance use history were collected retrospectively from the initial palliative care consultation. At initial palliative care consultation clients discuss their code status with the physician (i.e. “full resuscitation” vs “Do not resuscitate”); this was also collected at the time of initial palliative care consultation from the electronic medical record.\u003c/p\u003e\n\u003ch3\u003eDescription of psychiatric services provided\u003c/h3\u003e\n\u003cp\u003eInformation on the reason for referral to psychiatry services and time to initial psychiatric consultation were collected retrospectively at the time of initial psychiatry consultation. Measures including the length of the therapeutic relationship with the psychiatry team, diagnostic impression, visit type (virtual vs outreach), therapies offered, and reason for discontinuing services were collected retrospectively from the time of psychiatric consultation.\u003c/p\u003e\n\u003ch3\u003eData collection and analysis\u003c/h3\u003e\n\u003cp\u003eAll data were collected retrospectively from the electronic medical record. Descriptive statistics were used to describe the cohort, and for confidentiality we have not reported any small cell sizes (N \u0026lt; 3). Data are reported in frequency along with percentage of the cohort. Data were verified by 3 separate members of the team for accuracy. Research ethics approval was obtained from the St.Michael’s Hospital Research Ethics Board (REB#23 − 004).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDemographics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 2019 to May 2023, a total of 62 clients were referred to the PEACH Psychiatry team. Thirteen clients were excluded from the study as they were not formally seen by the psychiatry team, or had declined palliative care services. Among the 48 clients included in this dataset, the majority identified as male (77.1%), were aged 50 to 70 (68.7%) and resided in subsidized housing (43.7%) or shelter (31.2%) at time of referral to psychiatry. See Table 1 for details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReferral information\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were primarily referred for assistance with psychiatric symptom management (45.8%), while many others were referred for support around coping with a life-threatening illness (22.9%). Many clients were referred to psychiatry within 1 week of palliative care consultation (31.3%); however, a majority of clients were referred 12 weeks or longer after initial involvement with the palliative care team (39.6%). Clients were typically seen by the psychiatry service within 1-4 weeks (58.3%) of referral. Fifty percent of the clients had two or more previous psychiatric diagnoses; depressive, substance use, and psychotic disorders were the most common prior diagnoses. Most clients had a substance use disorder of 1 or more substances (55.1%). Clients referred to psychiatry typically had a Palliative Performance Scale score of \u0026gt;60% (67.3%), and the majority had malignancy as a primary palliative diagnosis (61.2%). See Table 2 for details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePsychiatry therapeutic relationship\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of clients referred to psychiatry were seen 2 - 4 times (41.7%); however, 11 clients were seen over 10 times (22.9%). Most clients (68.7%) were seen exclusively by in-person community visits, and 35.4% of clients were followed for over twelve months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTherapies/services provided by the psychiatric team\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most common diagnostic impression after psychiatric involvement was substance use disorder (25%) followed by an equal split between delirium/neurocognitive disorders (16.6%), mood disorders (16.6%), and 16.6% of patients with either normative distress or with an unclear diagnostic picture. The therapies provided by the psychiatry team included psychotropic medication modification/initiation and psychotherapy (41.7%), psychotherapy alone (22.9%), supportive counselling (14.6%) and diagnostic clarification (12.5%). Four clients (8.3%) had limited assessment and did not have any therapies provided. Death was the most common reason for discontinuing psychiatry services (37.5%). Nine clients (18.8%) were seen for a one time consultation. Otherwise, the psychiatric relationship remains ongoing for 18 clients (36.7%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eKey Findings\u003c/h2\u003e\u003cp\u003eThis study describes a novel model of integrated psychiatric care for a community-based palliative care team that serves structurally vulnerable populations. Most clients are seen in an exclusively outreach model and are offered both psychotherapy and psychotropic medication management. Only one client declined further services after initial psychiatric consultation; for most clients, services were only discontinued after they were transferred to hospice or died. Clients were referred quickly, most within 1 week, after assessment by a palliative care physician, and most clients received services for 2\u0026ndash;4 visits. Some clients had longitudinal follow-up over 12 months, emphasizing the importance of early referrals to maximize the impact of psychiatric interventions in palliative care.\u003c/p\u003e\u003cp\u003eOur results suggest that the role of psychiatry in palliative care for structurally vulnerable populations has a broad scope, ranging from diagnostic clarification, treatment recommendations, ongoing support and psychotherapy, informal support for the care team, liaison with inpatient providers, and one-off consultation to aid with capacity assessment. This integrated model allows for clients living with mental illness and those without mental illness who need psychosocial support to have access to both psychiatric care and symptom management when living with a life threatening illness.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eWhat this study adds\u003c/h2\u003e\u003cp\u003ePrevious literature has highlighted that collaborations between psychiatry and palliative care can be challenging to achieve through mainstream services (\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This study describes a model that takes a unique approach of integrating community based psychiatry with community based palliative care, creating a low barrier for referral for structurally vulnerable clients to receive psychiatric services. Previous studies have shown that integrated psychiatry and physical health services can lead to improved vaccination rates and chronic disease screening for people living with mental illness (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, no previous studies have described a model of integrated psychiatry and palliative care. This study underlines the importance of integration as a method of providing collaborative care for those living with life threatening disease and mental illness. It also highlights the potential of a model to provide care in the community with a patient centered focus that reduces barriers to accessing palliative care for people living with mental illness.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Weaknesses/ Limitations\u003c/h2\u003e\u003cp\u003eThis study\u0026rsquo;s strength is that it is the first to our knowledge to describe a model of integrated psychiatric and community based palliative care for structurally vulnerable people.\u003c/p\u003e\u003cp\u003eThe limitations of the study include the lack of healthcare utilization data for this cohort. Additionally, the study's quantitative nature leaves gaps in understanding the qualitative impact on patients and providers. Finally, this study cannot make any conclusions about the impact of the PEACH psychiatry service, including its acceptability, given that the data are descriptive and do not include outcomes or patient perspectives.\u003c/p\u003e\u003cp\u003eBecause PEACH psychiatry represents a model of integrated care, another limitation of this study is that we have not described patients followed by PEACH that receive psychiatric care from other community psychiatry teams. This is often the case for patients with SPMI who may have close relationships with, e.g., Assertive Community Treatment or similar teams. In an effort to enhance access to both mental health and palliative care for patients with SPMI, there may be a tension between prioritizing existing relationships \u0026ndash; which in some cases are deep and longstanding \u0026ndash; and the virtues of integrated mental health and palliative care (e.g., shared information systems, co-location, etc.). Indeed, depending on the needs of the patient, a more traditional community psychiatry team may be best suited to provide mental health care in collaboration with a separate community palliative care team. This might be the case, for example, if there is a need for psychiatric case management, supervised medication administration, or mandatory outpatient treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eNext Steps\u003c/h2\u003e\u003cp\u003eA growing network of programs in Canada\u0026rsquo;s major cities provides palliative care to individuals who are precariously housed. We hope the PEACH psychiatry model can inspire the integration of psychiatric care into community-based palliative care programs for structurally vulnerable populations. Future studies should evaluate how integrated models of palliative and psychiatric care impact healthcare utilization and patient outcome measures. Qualitative studies are also needed to provide deeper insights into the experiences of both patients and providers within these integrated care frameworks. Finally, expanding education and training in this subspecialized area of psychiatry is crucial to equip professionals with the skills needed to effectively engage with and support this vulnerable population.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study describes a novel integrated psychiatry service within a community-based palliative care program for structurally vulnerable populations. The PEACH psychiatry team provides an innovative approach to care by addressing unique challenges of caring for structurally vulnerable populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSPMI - Severe and Persistent Mental Illness\u003c/p\u003e\n\u003cp\u003ePEACH - Palliative Education and Care for the Homeless\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eResearch Ethics Board approval status:\u0026nbsp;\u003c/strong\u003eApproved by the Unity Health Toronto Research Ethics Board (REB#23-004), research conducted in accordance to the Health Canada Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e As this was a retrospective chart review consent was no obtained from participants and data was anonymized\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e OT, JS, LT, DR, TM and ND do not have any competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources:\u003c/strong\u003e None, self-funded\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Author Contributions\u003c/p\u003e\n\u003cp\u003eOT (Toronto, Canada)– Primary author, Project coordinator contributed to data analysis and manuscript writing.\u003c/p\u003e\n\u003cp\u003eJS (Toronto, Canada) – Second author,; involved in data analysis and manuscript writing.\u003c/p\u003e\n\u003cp\u003eLT (MD, FRCPC) (Toronto, Canada) –; co-author.\u003c/p\u003e\n\u003cp\u003eND (MSC, MD, CCFP(PC), BSc) (Toronto, Canada) – Founder and Lead of PEACH; contributed to the study design and, co-author.\u003c/p\u003e\n\u003cp\u003eDR (MD, FRCPC) (Toronto, Canada) – Lead psychiatrist on the PEACH psychiatry team; co-Principal Investigator; contributed to the conceptualization of the study; co-author.\u003c/p\u003e\n\u003cp\u003eTM (MD, CCFP(PC) (Toronto, Canada) – PEACH palliative care physician, PEACH Research Lead; Co- Principal Investigator, contributed to the conceptualization of the study, co-author\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBuchanan N, Dosani N, Bond A, et al. Palliative Education and Care for the Homeless (PEACH): A Model of Outreach Palliative Care for Structurally Vulnerable Populations. \u003cem\u003eHealthc Q\u003c/em\u003e. 2023; 26(1):24-30. doi:10.12927/hcq.2023.27055\u003c/li\u003e\n\u003cli\u003eSchneider E, Dosani N. Retrospective study of a Toronto-based palliative care program for individuals experiencing homelessness. Journal of Palliative Medicine. 2021 ; 24(8):1232-5.\u003c/li\u003e\n\u003cli\u003eHudson BF, Flemming K, Shulman C, Candy B. Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research. BMC Palliative care. 2016; 15:1-8.\u003c/li\u003e\n\u003cli\u003eKlop HT, De Veer AJ, Van Dongen SI, Francke AL, Rietjens JA, Onwuteaka-Philipsen BD. Palliative care for homeless people: a systematic review of the concerns, care needs and preferences, and the barriers and facilitators for providing palliative care. BMC palliative care. 2018; 17:1-6.\u003c/li\u003e\n\u003cli\u003eStringfellow EJ, Kim TW, Pollio DE, Kertesz SG. Primary care provider experience and social support among homeless-experienced persons with tri-morbidity. Addiction Science \u0026amp; Clinical Practice. 2015; 10:1-2.\u003c/li\u003e\n\u003cli\u003eFazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS medicine. 2008; 5(12):e225.\u003c/li\u003e\n\u003cli\u003eZumstein N, Riese F. Defining severe and persistent mental illness\u0026mdash;a pragmatic utility concept analysis. Frontiers in psychiatry. 2020; 11: 648.\u003c/li\u003e\n\u003cli\u003eFoti ME. \u0026quot; Do It Your Way\u0026quot;: A Demonstration Project on End-of-Life Care for Persons with Serious Mental Illness. Journal of Palliative Medicine. 2003; 6(4):661-9.\u003c/li\u003e\n\u003cli\u003eHuang HK, Wang YW, Hsieh JG, Hsieh CJ. Disparity of end-of-life care in cancer patients with and without schizophrenia: a nationwide population-based cohort study. Schizophrenia research. 2018; 195:434-40.\u003c/li\u003e\n\u003cli\u003eWoods A, Willison K, Kington C, Gavin A. Palliative care for people with severe persistent mental illness: a review of the literature. The Canadian Journal of Psychiatry. 2008; 53(11):725-36.\u003c/li\u003e\n\u003cli\u003eChochinov HM, Martens PJ, Prior HJ, Kredentser MS. Comparative health care use patterns of people with schizophrenia near the end of life: a population-based study in Manitoba, Canada. Schizophrenia research. 2012; 141(2-3):241-6.\u003c/li\u003e\n\u003cli\u003eHinrichs KL, Woolverton CB, Meyerson JL. Help me understand: providing palliative care to individuals with serious mental illness. American Journal of Hospice and Palliative Medicine. 2022; 39(2):250-7.\u003c/li\u003e\n\u003cli\u003eDonald EE, Stajduhar KI. A scoping review of palliative care for persons with severe persistent mental illness. Palliative \u0026amp; supportive care. 2019;17(4):479-87.\u003c/li\u003e\n\u003cli\u003eMasel EK, Antunes B, Schulz-Quach C. Palliative care in severe mental illnesses. BMC Palliative Care. 2023; 22(1):31.\u003c/li\u003e\n\u003cli\u003eMarti, L., H\u0026uuml;nerwadel, E., Hut, B. et al. Characteristics and clinical challenges in patients with substance use disorder in palliative care\u0026mdash;experience from a tertiary center in a high-income country. BMC Palliat Care. 2024; 23(28). 2024. https://doi.org/10.1186/s12904-024-01366-x\u003c/li\u003e\n\u003cli\u003eRodgers M, Dalton J, Harden M, Street A, Parker G, Eastwood A. Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness: A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations. Int J Integr Care. 2018; 18(1):9. doi:10.5334/ijic.2605\u003c/li\u003e\n\u003cli\u003eBradford DW, Cunningham NT, Slubicki MN, et al. An evidence synthesis of care models to improve general medical outcomes for individuals with serious mental illness: a systematic review. J Clin Psychiatry. 2013; 74(8):e754-e764. doi:10.4088/JCP.12r07666\u003c/li\u003e\n\u003cli\u003eMcNamara B, Same A, Rosenwax L, Kelly B. Palliative care for people with schizophrenia: a qualitative study of an under-serviced group in need. BMC Palliat Care 2018; 17(53).\u003c/li\u003e\n\u003cli\u003eRiley, K, Hupcey, JE, Kowalchik, K. Palliative Care in Severe and Persistent Mental Illness: A Systematic Review. Journal of Hospice \u0026amp; Palliative Nursing. 2022; 24(3):p E88-E93 | DOI: 10.1097/NJH.0000000000000855\u003c/li\u003e\n\u003cli\u003eBloomer, M \u0026amp; O\u0026apos;Brien AP. Palliative care for the person with a serious mental illness: The need for a partnership approach to care in Australia, Progress in Palliative Care. 2013; 21(1), 27-31, DOI: 10.1179/1743291X12Y.0000000033\u003c/li\u003e\n\u003cli\u003eWard G, Holliday N, Coad J. Barriers to palliative care for people with severe mental illness: exploring the views of clinical staff. European Journal of Palliative Care. 2018; 25(1).\u003c/li\u003e\n\u003cli\u003eRodin G, Hales S. Managing cancer and living meaningfully: an evidence-based intervention for cancer patients and their caregivers. Oxford University Press. 2021 Apr 27.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Palliative care, mental illness, psychiatry care, homelessness, structural vulnerabilities, integrated care, end of life care","lastPublishedDoi":"10.21203/rs.3.rs-7302203/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7302203/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePeople experiencing homelessness have higher morbidity rates and lower life expectancy than the general population. Additionally, there is a high prevalence of mental illness and substance use disorders within this group, which compounds their health issues and adds complexity to providing palliative care. The Palliative Education and Care for the Homeless (PEACH) program in Toronto provides palliative care to this population, and includes an integrated psychiatry service to support clients with mental illness. The aim of this paper is to describe a novel model of integrated psychiatric care and palliative care for structurally vulnerable people living with life-threatening illness and complex mental health needs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a cross-sectional retrospective cohort study, collecting data from all patients referred to the PEACH psychiatry service in Toronto, Ontario, Canada from 2019 to 2023. The study included patients currently followed by PEACH Psychiatry, those deceased or discharged, and those referred but not assessed. Descriptive statistics were used to analyze the data.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOut of 62 clients referred to PEACH psychiatry, 48 were included in the analysis. The majority were male (77.1%) and were aged 50\u0026ndash;70 (68.7%). Referrals were primarily for psychiatric symptom management (45.8%) and support around coping with life-threatening illness (22.9%). Half of the clients had two or more psychiatric diagnoses, with depressive disorders, substance use disorder, and psychotic disorders being most common. Substance use disorder was the most common diagnostic impression post-assessment by psychiatry (25%). Therapies provided included medication management, psychotherapy, and diagnostic clarification.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study outlines a model of integrated psychiatric care within a community-based palliative team serving structurally vulnerable populations. This kind of integrated care represents an important service to improve delivery of both palliative care and psychiatric support for structurally vulnerable populations.\u003c/p\u003e","manuscriptTitle":"Integrating Psychiatry into a Community Based Palliative Care Team for People Experiencing Homelessness: A Descriptive Retrospective Cohort Study of the PEACH Psychiatry Program Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 15:13:01","doi":"10.21203/rs.3.rs-7302203/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-10T06:13:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-07T17:44:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252974117153866519372258379336347213751","date":"2025-10-05T11:41:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-04T15:23:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291208824282439897063318720102201938335","date":"2025-08-14T16:50:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T07:16:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-08T10:19:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-08T03:50:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-08T03:49:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-08-05T15:10:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10e1e5df-df1b-41cb-9ff2-3ce92ad1829e","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:02:00+00:00","versionOfRecord":{"articleIdentity":"rs-7302203","link":"https://doi.org/10.1186/s12904-026-01996-3","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2026-01-21 15:58:41","publishedOnDateReadable":"January 21st, 2026"},"versionCreatedAt":"2025-08-21 15:13:01","video":"","vorDoi":"10.1186/s12904-026-01996-3","vorDoiUrl":"https://doi.org/10.1186/s12904-026-01996-3","workflowStages":[]},"version":"v1","identity":"rs-7302203","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7302203","identity":"rs-7302203","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}