Addressing Palliative Care Needs for a Housing-Insecure Patient with Metastatic Renal Cell Carcinoma and Severe Mental Illness: A Case Report

Abstract

Palliative care for underserved populations presents unique challenges due to complex medical, psychiatric, and social needs. We report a case of a 54-year-old housing-insecure male with schizophrenia and metastatic chromophobe renal cell carcinoma, initially diagnosed during hospitalization for a seizure and infection. Initially lacking capacity, he was deemed appropriate for hospice but was lost to follow-up after discharge to a skilled nursing facility. Re-engagement occurred through a Federally Qualified Health Center (FQHC) embedded in a homeless shelter, where care was delivered through an integrated, community-based model. The patient primarily interacted with his primary care physician, board-certified in family medicine and palliative care, while receiving support from behavioral health, outreach, and case management staff. Through coordinated efforts—including facilitation of oncology appointments, outreach support, and ongoing trust-building interactions—the patient adhered to partial radiation therapy and systemic treatment while maintaining autonomy and quality of life. This case highlights the importance of trauma-informed, patient-centered care, demonstrates how interdisciplinary collaboration can support complex decision-making, and underscores the role of community-based FQHC models in addressing social determinants of health while building trust and supporting patient autonomy for medically and socially complex individuals facing homelessness and severe mental illness.

Introduction

Palliative care aims to improve quality of life for patients with serious illnesses by addressing physical symptoms, psychological distress, social challenges, and spiritual needs. However, underserved populations—such as individuals experiencing housing instability, severe mental illness, and systemic marginalization—face significant barriers to accessing palliative care. These barriers often include a fragmented health care system, in which patients receive care from multiple disconnected providers without consistent communication, and a lack of continuity, which can result in delayed diagnoses, poor symptom management, and repeated hospitalizations. Stigma and logistical challenges, such as transportation and unstable housing, further complicate care.

Homeless and housing-insecure individuals with complex comorbidities, like metastatic cancer and schizophrenia, represent a uniquely vulnerable group requiring innovative, interdisciplinary approaches. Federally Qualified Health Centers (FQHCs) are community-based primary care clinics that receive federal funding to provide comprehensive care to underserved populations regardless of insurance status. FQHCs often integrate medical, behavioral health, and social services to reduce barriers and improve continuity of care.

In our clinic, the team includes primary care physicians, psychiatry providers, behavioral health specialists—including trauma recovery services and substance use counselors—and outreach workers trained in community engagement and substance use support. While the patient in this case primarily interacted with his primary care physician, who is board-certified in family medicine and palliative care and continues to practice clinically, the broader team provided advice, support, and continuity through ongoing outreach and clinic interactions. This case illustrates the challenges and successes of providing community-based palliative care to a patient navigating advanced renal cell carcinoma alongside significant social and psychiatric barriers.

Case Presentation

A 54-year-old male with unknown past medical history presented to the emergency department after his caseworker performed a welfare check due to a lack of contact for approximately one month. The patient was found in poor hygiene, covered in feces and insects, and experienced a tonic–clonic seizure while being transported by emergency medical services. Initial workup revealed a urinary tract infection treated with intravenous antibiotics. Neuroimaging showed no acute intracranial abnormalities.

Psychiatry evaluated the patient and diagnosed schizophrenia with possible acute delirium in the context of chronic alcohol use. He was deemed to lack capacity for medical decision-making. Incidentally, imaging identified metastatic renal cell carcinoma. Oncology assessed that the patient lacked understanding of his diagnosis and recommended no further oncologic intervention, considering hospice appropriate. Case management facilitated discharge planning to a skilled nursing facility. The patient was lost to follow-up after discharge.

The patient re-engaged with care approximately seven months later at an FQHC embedded in a homeless shelter. He was referred to the medical clinic, where he saw a physician who also provides palliative care. After discussing his goals of care, symptoms, and interest in treatment, the physician submitted an order for oncology referral. The clinic’s referral team worked with insurance for approval, and the medical assistant, who served as an informal case manager, coordinated scheduling, transportation, and logistics, including providing a contact number since the patient did not have a phone. The patient was scheduled for biweekly, then monthly, follow-up appointments with the clinic, with the team even walking to his apartment when needed to ensure continuity.

The patient saw oncology regularly and was admitted approximately six months later, during which an attempted left radical nephrectomy was halted due to high surgical risk from tumor invasion of the colonic mesentery. Palliative radiation therapy was initiated, though only partially completed because the patient opted to leave the hospital against medical advice to attend to personal priorities and declined additional social work assistance. Follow-up revealed new metastatic disease in the right shoulder.

Despite complex medical and social challenges, the patient maintained a reasonable quality of life and continued to engage with a multidisciplinary team including oncology, behavioral health, outreach, and case management services.

Assessment of Needs

This patient’s palliative care needs were multifaceted, encompassing physical symptoms from metastatic renal cell carcinoma, psychiatric comorbidities including schizophrenia and substance use, and significant social vulnerabilities such as housing instability and fragmented care. Individuals experiencing homelessness or vulnerable housing face unique barriers to palliative care, including limited transportation, inability to make appointments due to lack of a phone, and restricted access to a safe home environment for receiving care. These barriers can be further compounded by care avoidance stemming from prior experiences of stigma within health care settings. ¹

Physically, the patient experienced cancer-related symptoms including pain, fatigue, and disease progression, all of which required careful symptom management and coordination of treatment. Psychologically, he faced challenges related to mental illness, impaired decision-making capacity, and anxiety about treatment, necessitating supportive behavioral health interventions.

Social determinants of health profoundly impacted care, particularly housing insecurity and periods of homelessness that created obstacles to medication adherence and consistent follow-up. A patient-centered, flexible, and low-threshold approach—attuned to the specific concerns of individuals experiencing homelessness—was necessary to provide timely and effective palliative care. ² Establishing trust and rapport was essential; clinicians who invest the time to build relationships with vulnerable patients at the end of life can facilitate engagement while also finding personal and professional fulfillment in supporting patients to face death with dignity. ³

Intervention

To address this patient’s complex needs, we employed a whole-person, patient-centered approach grounded in palliative care principles, tailored to the constraints and opportunities of an FQHC embedded in a homeless shelter. The patient was primarily followed by his physician, board-certified in family medicine and hospice/palliative care, who served as the central clinician coordinating care. Although the patient declined behavioral health services, he continued to interact with the physician, clinic medical assistants, and outreach staff, who collectively provided informal case management and facilitated engagement.

Referral to oncology was initiated by the physician following discussions with the patient regarding his goals of care, symptoms, and interest in treatment. The clinician placed the referral order, which was then processed by the clinic referral team in coordination with the patient’s insurance. The medical assistant, acting as an informal case manager, collaborated with the referral team to coordinate appointment scheduling, transportation, and provision of a clinic phone number for patient use, as he did not have personal phone access. Medication access was facilitated through the clinic and outreach team, ensuring the patient could obtain prescriptions reliably despite housing instability and lack of transportation. Housing support was coordinated in collaboration with community organizations, assisting the patient in maintaining placement in permanent supportive housing.

Follow-up visits were scheduled biweekly initially and then monthly, with the team occasionally accompanying the patient to his apartment to ensure continuity, adherence, and safety. These in-person interactions, occurring multiple times per week initially, were crucial for building trust, allowing the patient to engage more openly with the care team, ask questions, and express his preferences. The flexibility of meeting him in his environment helped overcome logistical and relational barriers, reinforcing rapport and empowering him to participate in decision-making.

This structure exemplifies how palliative care principles—comprehensive assessment, care coordination, and continuity—can be applied even in nontraditional, resource-constrained settings, supporting medically and socially complex patients to pursue their care goals effectively.^2,4

Outcomes

Despite ongoing medical and social challenges, the patient maintained a reasonably good quality of life. Although he was not very verbally communicative, he seemed to derive satisfaction and a sense of autonomy from maintaining and keeping his home clean. His daily activities included walking to the clinic and the nearby meal program, where he enjoyed coffee, a sweet treat, and stepping outside for a cigarette. These routines appeared to provide him with structure, mobility, and small moments of personal enjoyment.

Although he did not have known active family connections, he shared partial names and birthdates of some family members but did not provide full details. Previous attempts to reach his case manager to follow up on family contacts were unsuccessful, and the patient did not wish for further efforts to locate them. Despite this, he maintained meaningful social interactions within the care team. He would request the medical assistant by name for coffee and consistently recognized the faces of outreach workers and other staff, highlighting the importance of familiar, trusting relationships in his life.

The patient had experienced intermittent periods of homelessness prior to engagement with permanent supportive housing, which remained his residence throughout the follow-up period. Social engagement through informal interactions at the clinic and in the community seemed to help mitigate isolation, support adherence to care, and promote a sense of belonging.

Symptom management—including pain, fatigue, and anxiety—was facilitated through frequent clinic visits, occasional home visits, and coordination with oncology and palliative care providers, ensuring ongoing assessment and support. Flexible scheduling and in-person support appeared to allow him to participate in partial radiation therapy and systemic treatment aligned with his goals of care, preserving autonomy and maintaining stability in his daily life.

This case demonstrates that even for medically and socially complex patients with limited verbal communication, trauma-informed, community-based palliative care can support meaningful quality of life, autonomy, and social connection.^1–3

Discussion

This case highlights the multifaceted nature of palliative care needs among housing-insecure patients with severe mental illness and metastatic cancer. The patient’s clinical course underscores the importance of an integrated, whole-person approach that simultaneously addresses physical symptoms, psychiatric comorbidities, and social determinants of health. Coordinated care within an FQHC embedded in permanent supportive housing created a unique opportunity to bridge traditional gaps in oncology and palliative services for this vulnerable population. Even without a traditional inpatient palliative care team, frequent in-person visits, flexible scheduling, and coordination across clinic, outreach, and oncology providers allowed for comprehensive, continuous support aligned with palliative care principles. ⁴

Notably, informal social engagement—such as stopping by for coffee, building rapport with staff, and recognizing familiar faces—played a critical role in fostering trust and enhancing therapeutic relationships. These interactions seemed to empower the patient, mitigate feelings of isolation, and encourage proactive participation in his care. This aligns with evidence that flexible, low-threshold, and patient-centered approaches are effective for providing palliative care to people experiencing homelessness.^1–3 Maintaining autonomy through participation in care on his own terms—including leaving the hospital against recommendations—was supported by trauma-informed, community-based care that respected his priorities and allowed him to remain engaged with treatment aligned with his goals.

This case also underscores the importance of continuity and coordination. Regular visits, in-person support, and consistent presence of familiar staff helped stabilize the patient’s daily routines, supported symptom management, and facilitated adherence to partial radiation therapy and systemic treatment. Even for patients with limited verbal communication, such approaches appeared to preserve quality of life, autonomy, and meaningful social connection.^1–3

In summary, this case supports adopting community-based, interdisciplinary palliative care models within primary care and social service frameworks to serve medically and socially complex patients experiencing homelessness and severe mental illness. Such models can promote trust, continuity, autonomy, and meaningful quality of life despite substantial barriers.