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Hospital discharge planning for Canadians experiencing homelessness



Purpose People experiencing homelessness are high-users of hospital care in Canada. To better understand the scope of the issue, and how these patients are discharged from hospital, a national survey of key stakeholders was conducted in 2017. The paper aims to discuss this issue. Design/methodology/approach The Canadian Observatory on Homelessness distributed an online survey to their network of members through e-mail and social media. A sample of 660 stakeholders completed the mixed-methods survey, including those in health care, non-profit, government, law enforcement and academia. Findings Results indicate that hospitals and homelessness sector agencies often struggle to coordinate care. The result is that these patients are usually discharged to the streets or shelters and not into housing or housing with supports. The health care and homelessness sectors in Canada are currently structured in a way that hinders collaborative transfers of patient care. The three primary and inter-related gaps raised by survey participants were: communication, privacy and systems pressures. Research limitations/implications The findings are limited to those who voluntarily completed the survey and may indicate self-selection bias. Results are limited to professional stakeholders and do not reflect patient views. Practical implications Identifying systems gaps from the perspective of those who work within health care and homelessness sectors is important for supporting system reforms. Originality/value This survey was the first to collect nationwide stakeholder data on homelessness and hospital discharge in Canada. The findings help inform policy recommendations for more effective systems alignment within Canada and internationally.
Housing, Care and Support
Hospital discharge planning for Canadians experiencing homelessness
Kristy Buccieri, Abram Oudshoorn, Tyler Frederick, Rebecca Schiff, Alex Abramovich, Stephen Gaetz, Cheryl Forchuk,
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Kristy Buccieri, Abram Oudshoorn, Tyler Frederick, Rebecca Schiff, Alex Abramovich, Stephen Gaetz, Cheryl Forchuk,
(2018) "Hospital discharge planning for Canadians experiencing homelessness", Housing, Care and Support, https://
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Hospital discharge planning for Canadians
experiencing homelessness
Kristy Buccieri, Abram Oudshoorn, Tyler Frederick, Rebecca Schiff, Alex Abramovich,
Stephen Gaetz and Cheryl Forchuk
Purpose People experiencing homelessness are high-users of hospital care in Canada. To better
understand the scope of the issue, and how these patients are discharged from hospital, a national survey of
key stakeholders was conducted in 2017. The paper aims to discuss this issue.
Design/methodology/approach The Canadian Observatory on Homelessness distributed an online survey
to their network of members through e-mail and social media. A sample of 660 stakeholders completed the
mixed-methods survey, including those in health care, non-profit, government, law enforcement and academia.
Findings Results indicate that hospitals and homelessness sector agencies often struggle to coordinate
care. The result is that these patients are usually discharged to the streets or shelters and not into housing or
housing with supports. The health care and homelessness sectors in Canada are currently structured in a
way that hinders collaborative transfers of patient care. The three primary and inter-related gaps raised by
survey participants were: communication, privacy and systems pressures.
Research limitations/implications The findings are limited to those who voluntarily completed the
survey and may indicate self-selection bias. Results are limited to professional stakeholders and do not reflect
patient views.
Practical implications Identifying systems gaps from the perspective of those who work within health
care and homelessness sectors is important for supporting system reforms.
Originality/value This survey was the first to collect nationwide stakeholder data on homelessness and
hospital discharge in Canada. The findings help inform policy recommendations for more effective systems
alignment within Canada and internationally.
Keywords Canada, Privacy, Hospital, Patients, Homelessness, Systems alignment
Paper type Research paper
Homelessness is an experience that intersects with multiple social determinants of health, such
as inequitable income distribution, unemployment, food insecurity, inadequate housing, disability
and social exclusion (Mikkonen and Raphael, 2010). Yet despite health inequities, many
individuals who experience homelessness do not have a regular physician and instead rely on
hospitals for care. Researchers have found high rates of hospital use among individuals
experiencing homelessness (Tadros et al., 2016), most commonly for injuries resulting in sprains,
strains, contusions, abrasions and burns (Mackelprang et al., 2014). Canadian studies have
recorded high percentages of homeless individuals who report at least one hospital visit in the
preceding year, with figures as high as 77 percent (Hwang and Henderson, 2010). This indicates
that a large number of homeless individuals rely on hospitals for their health care needs,
sometimes on multiple occasions throughout any given year (Kushel et al., 2002).
In Canada, homelessness costs the Canadian economy $7.05bn annually and institutional care,
such as hospitalization, contributes significantly to this amount (Gaetz et al., 2013). Recent
indicators suggest that the annual cost of hospitalization of homeless persons is $2,495
compared to $524 for housed persons (Gaetz, 2012; Hwang and Henderson, 2010). Examining
expenditures in four Canadian cities, Pomeroy (2005) calculates the cost of institutional
responses to homelessness, such as hospitalization, as adding up to $120,000 per person
annually. Clearly, there are social and economic costs associated with inadequate levels of care
for persons experiencing homelessness.
Kristy Buccieri is based at
Trent University,
Peterborough, Canada.
Abram Oudshoorn is Assistant
Professor at
Western University,
London, Canada.
Tyler Frederick is based at
the Institute of Technology,
University of Ontario,
Oshawa, Canada.
Rebecca Schiff is Associate
Professor at
Lakehead University,
Thunder Bay, Canada.
Alex Abramovich is
Independent Scientist at
the Centre for Addiction and
Mental Health,
Toronto, Canada.
Stephen Gaetz is based at
York University,
Toronto, Canada.
Cheryl Forchuk is based at
Western University,
London, Canada.
DOI 10.1108/HCS-07-2018-0015 © Emerald Publishing Limited, ISSN 1460-8790
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Although individuals experiencing homelessness may have a higher acuity or co-morbid
conditions that partially explain their more frequent use of hospitals, a notable concern is whether
they are receiving timely and appropriate discharge (Cornes et al., 2017). The purpose of
conducting this national survey was to understand how Canadian hospital and homeless-serving
stakeholders perceive hospital discharge processes and outcomes for these patients.
Canadian context
Canada is a wealthy nation with a population of over 36m. The most recent national data indicate
that at least 235,000 Canadians experience homelessness every year and that of these
individuals 27.3 percent are women, 18.7 percent are youth, and within shelter populations
24.4 percent are older than 50 and 2834 percent are identified as indigenous (Gaetz et al.,
2016). Individuals identified as lesbian, gay, bisexual, transgender, queer or 2-spirit are
disproportionately represented among the homeless population in Canada (Abramovich, 2016;
Gaetz et al., 2016).The homeless population has changed over time in Canada, from a small
number of single adult males in the 1980s to a mass problem in the mid-2000s (Gaetz et al.,
2016). The increase in homelessness and the demographic changes can be traced to federal
divestment in affordable housing through policy changes made in the 1980s and 1990s; the
dismantling of Canadas national housing strategy at that time had arguably the most profound
impact on the rise of homelessness (Gaetz, 2010). At present Canada is undergoing a renewed
investment in affordable housing, through new initiatives such as the National Housing Strategy
(Government of Canada, 2017) and Homelessness Strategy (Government of Canada, 2018). This
shift away from an emergency response toward prevention and transition is in part due to the
widespread adoption of Housing First, a recovery-oriented model that aims to rapidly and
securely house individuals and then provide the wrap-around supports they need. Housing First
was developed at Pathways to Housing in New York (Padgett et al., 2016) and was proven
effective in the landmark multi-site Canadian evaluation of over 2,000 participants, known as the
At-Home/Chez Soi study (Goering et al., 2014).
The Housing First approach increasingly being adopted in Canada represents a shift toward
integrated systems approaches (Nichols and Doberstein, 2016). This work is informed by the Calgary
Homeless Foundations(2014)systems of careplanning, which is comparable to the London
Pathway approach (Hewett, 2013; Powell and Hewett, 2011). There are several national bodies that
inform and advocate for coordinated systems approaches, such as the Canadian Observatory on
Homelessness and the Canadian Alliance to End Homelessness. However, the organization of
Canadas political system into federal, provincial/territorial, and municipal governments makes it
challenging to align factors such as mandates, budgets and information sharing (Buccieri, 2016).
For instance, since health care is managed at the provincial and territorial level in Canada, there are
13 independent ministries that oversee service planning and provision based on geographic location.
Furthermore, housing is also a provincial-level issue but is overseen by different ministries than health,
and many provinces further download housing and homelessness planning to municipal
governments, many of whom operate alongside non-for-profit organizations. Thus, each level of
government has its responsibilities and oversight but they are not always well integrated.
The unintended outcome of this political approach is disjointed health and social care, particularly
for vulnerable populations. Canada operates under universal health care but researchers have
found that hospitals have limited resources to meet increasing needs and are frequently
overcrowded (Zhao et al., 2015). While the international standard for safe occupancy is
85 percent, in the summer of 2017 half of the hospitals in Ontario, Canadas most populated
province, were at or above 100 percent occupancy, sometimes reaching as high as 140 percent
(Ontario Hospital Association, 2018). Delayed discharge can increase occupancy and lead to
capacity strain in emergency departments and increased wait times across the system (Forster
et al., 2003). Therefore, the fact that 13 percent of hospital beds in Canada are occupied by those
no longer requiring hospital care but awaiting discharge to an appropriate service (CIHI, 2010) is
of vital concern. The literature review that follows details what is known about hospital usage and
discharge planning for persons experiencing homelessness in Canada and establishes the
foundation for the study.
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Literature review
Discharging individuals from hospital directly to shelters or the street is common but
under-explored in the Canadian literature (Forchuk et al., 2006). Pauly (2014) notes that in
Canada, clients get dumped into the communitythrough discharge to shelters or the street
without any discharge planning around housing and community supports. However, some North
American research clearly shows that when coordinated discharge planning for homeless
individuals occurs, it leads to decreases in hospital visits (Raven et al., 2011; Sadowski et al., 2009),
supports housing stability (Forchuk et al., 2008), is cost-effective (Forchuk et al., 2013) and is
possible using a systems-approach that integrates sectors (Stergiopoulos et al., 2016) through
the implementation of evidence-based practices (Best and Young, 2009). Yet, despite this literature
showing the positive outcomes of coordinated discharge, inappropriate or incomplete discharge
practice is a common occurrence for individuals experiencing homelessness.
Patients with complex social needs may require a dedicated discharge planner in order for discharge
to occur in a timely manner. For people experiencing homelessness, increased length of stay is seen
both in acute beds and in Alternate Level of Care beds, meaning patients who do not require acute
care resources but remain hospitalized (Hwang et al., 2011). While much of the literature on health
care utilization among those experiencing homelessness focuses on high emergency department
use, these high rates carry into admitted acute care as well (Fazel et al., 2014). For example, Hwang
et al. (2013) analyzed health service utilization among 1,165 people experiencing homelessness and
found a 4.22 rate ratio for medical-surgical hospitalization compared to the general population.
Similarly, Russolillo et al. (2016) studied admissions and length of stay for 433 individuals in the
10 years prior to their intake into a Housing First program; they found an average of 6 admissions
over 10 years, increasing from 0.3 to 1.2 over the 10-year period. Likewise, mean days in hospital
increased from 2.4 to 16.9. These admissions are in part due to compounding factors of higher rates
of morbidity with lower rates of access to health services in the community, such as primary care.
Within hospitals, patient discharge may be the responsibility of nurses but often they have not
received training about how to address the non-medical needs of homeless individuals (Doran
et al., 2014). Without formal instruction, health care providers may not know what issues to
consider and/or how to address them. For instance, one American study of discharge practices
found that over half of the homeless participants were not asked about their housing status
(Greysen et al., 2013). There are several complicating factors common at discharge for any hospital
patient, including discontinuity between health care providers, changes to medication regimes, new
self-care responsibilities, stressors to available resources and complex discharge instructions
(Kripalani et al., 2007). In addition to managing these potential difficulties, patients experiencing
homelessness live with unstable social situations that may challenge standard discharge care (Best
and Young, 2009). This is evidenced in one study of recurrent hospitalization that found that
overcoming difficult life circumstances posed a greater barrier to recuperation than did a lack of
medical knowledge, strongly indicating a need to address underlying issues (Strunin et al., 2007).
Following discharge, re-presentation to hospital is common for patients experiencing
homelessness (Moore et al., 2010). Fader and Phillips (2012) note that patients experiencing
homelessness often lack access to the resources needed to maintain their health independently.
Sometimes referred to as a transition of care(Kripalani et al., 2007), properly executed
discharge planning should identify and organize the services that a person with mental illness,
substance abuse and/or other vulnerabilities needs when leaving an institutional or custodial
setting and returning to the community (Backer et al., 2007).
Recently some discharge models have begun to identify problem areas and show promising
interventions for vulnerable patients. Medical respite programs, for instance, have been shown to
assist people in their transitions of care from hospital and to provide ongoing support in the
community (Fader and Phillips, 2012) and coordinated discharge checklists have been shown to
be effective for discharge of patients experiencing homelessness (Best and Young, 2009). Among
the few reported studies on discharge of patients experiencing homelessness from acute mental
health services, the findings indicate that discharge directlyto transitional and/or supportive housing
drastically improves housing stability (Forchuk et al., 2006, 2008, 2013), reduces readmission rates
(Stergiopoulos et al., 2016) and lowers health care expenditures (Forchuk et al., 2013).
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Research question
Given the high system impact of service utilization by people experiencing homelessness and the
likelihood of delayed discharge, more information is needed to understand barriers and gaps
regarding timely discharge. Therefore, this paper addresses the question:
RQ1. What are the barriers and system gaps to timely discharge for people experiencing
homelessness from hospital to community in Canada?
The data presented in this paper were collected through an online survey conducted in July 2017.
The Canadian Observatory on Homelessness distributed a brief description of the survey and the
link to its members through e-mail and social media accounts. The purpose of the survey was to
collect national data on the issues impacting discharge planning for patients experiencing
homelessness. To capture a broad range of stakeholders, individuals working within health care,
non-profit sectors, government, research or other related fields within Canada were eligible to
participate. A total convenience sample of 660 participants completed the survey. All participants
provided informed consent, participation was voluntary and no remuneration was provided to
respondents. The study was reviewed and approved by the Research Ethics Board for research
involving human participants at Trent University.
To collect broad data from a large range of stakeholders, the survey was intentionally designed to
take no more than five minutes to complete and consisted of only eight questions. The first six
questions were basic demographics to situate participants geographically and in specific
sectors or roles. For the seventh question participants were given a series of eight statements
(see Table II) and asked to rate their level of agreement on a scale of 0100, with 100 indicating
the highest level of agreement. For the last question, participants were provided with an open box
and asked, Is there anything you would like to say about hospital discharge planning and/or
coordinated health care efforts for persons experiencing homelessness in your community?
Slightly more than half (51.5 percent) of the participants responded to this final question, resulting
in 340 comments for analysis.
Data from each of the eight questions are reported in this paper. The geographic, employment and
statement data from questions 1 to 7 are presented in chart form. The qualitative data from
question 8 were analyzed using a method of deductive coding (Guba and Lincoln, 1989), moving
from general to particular themes. The quotes were read several times, sorted into broad categories
and divided into sub-themes, identifying new ones as they emerged until saturation was achieved.
The demographic data indicated that more than half of the participants were located in the
province of Ontario, which is in Central-east Canada. Despite being clustered heavily in one
province, the geographic size was evenly distributed between small, mid-size and major
metropolitan areas. The majority of participants were employed in the social service or non-profit
sector and worked predominantly in non-managerial positions that involved direct contact with
persons experiencing homelessness (Table I).
Scope of the issue
Following from the literature on high rates of hospital usage by persons experiencing
homelessness (Hwang and Henderson, 2010; Kushel et al., 2002; Mackelprang et al., 2014;
Tadros et al., 2016), and discharge planning (Stergiopoulos et al., 2016), a series of statements
were constructed for the survey. For instance, based on Wen et al. (2007) finding that individuals
experiencing homelessness often feel unwelcome in health care settings, we posed a statement
about how well-supported stakeholders believe these patients are in hospitals. Questions about
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integration between health care and social care emerged from the work of Nichols and
Doberstein (2016), and questions about the discharge process were primarily informed by the
psychiatric discharge studies conducted by Forchuk et al. (2006, 2008, 2013).
Participants were asked to rate their agreement with each statement using a scale of 0100, with
higher numbers indicating stronger agreement. Across all statements, the data indicated strong
consensus that the need for improved discharge planning for this population is extremely high.
The data presented in Table II, particularly the median and mode for each statement,
demonstrate that stakeholders across Canada are struggling with the negative effects of
uncoordinated discharge planning for persons experiencing homelessness.
Barriers and gaps
Participants were given an opportunity to share any information they wished about discharge planning
and/or coordinated care for persons experiencing homelessness in their community. Analysis of the
340 submitted responses identified three contributing factors that serve as barriers or gaps to the
coordinated discharge of patients experiencing homelessness from hospital into supportive housing.
Participants, particularly those working in shelters, expressed frustration over the lack of
communication between sectors. A characteristic statement was, In 5 years of working at a
shelter for those experiencing homelessness, I have never had or witnessed hospital staff
(physical or mental health facility), include us in a hospital discharge plan.While there was
recognition that some hospital staff were familiar with the local agencies, this was viewed as a
function of the individual and not a systems-level practice. Participants expressed that, Hospital
discharge planners are often not aware of the resources in the community,”“Hospital social
workers need to continue to network with the community servicesand that communication from
hospitals is too haphazard and frustrating.Support workers shared the concern that without
their involvement discharge plans for their clients were not practical. One participant stated,
We have occasions when people are discharged without appropriate clothing/shoes.
Table I Participant demographics
n¼660 n% n%
Geographic location Sector
Ontario 383 58.0 Social service/non-profit 428 60.8
British Columbia 100 15.2 Hospital/health care 125 17.8
Alberta 68 10.3 Government 56 8.0
Manitoba 22 3.3 Other (legal, emergency) 43 6.1
Nova Scotia 12 1.8 Research 20 2.8
Quebec 8 1.2 Education 15 2.1
Newfoundland and Labrador 7 1.1 Policy 14 2.0
New Brunswick 6 0.9 Length in position (years)
Saskatchewan 6 0.9 05 214 34.9
Yukon 2 0.3 610 175 28.6
Northwest Territories 1 0.2 1120 127 20.1
Prince Edward Island 1 0.2 W21 94 15.3
Geographic size Work involves homelessness
Smaller metropolitan 183 29.7 Yes, directly 529 80.6
Mid-sized metropolitan 178 28.9 Yes, indirectly 120 18.3
Major metropolitan 174 28.3 No 3 0.5
Non-metro small city 36 5.8
Small town 35 5.7
Decision-maker in organization
No 405 68.9
Yes 171 29.1
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We have tried to communicate with our hospital to participate in discharge planning but have not
been successful.Another wrote, We have identified a trend in our community whereby the
hospital will discharge homeless or mentally ill patients late at night and typically on the weekend
in order to place inappropriate clients in our shelter.
Siloing between sectors was identified as a primary reason for the lack of mutual communication.
One participant noted that although their local hospital is trying to improve their discharge
planning they are, doing so using the typical silo methods that mean they will announce their
process changes to community service agencies and then be surprised when those same
agencies dont agree with the changes and wont comply.Poor communication between
hospitals and shelters was perceived to be contributing to the ongoing lack of coordinated
discharge for persons experiencing homelessness in Canada.
The lack of communication was attributable, at least in part, to privacy concerns around the
sharing of confidential information. Participants working in social service sectors felt that medical
professionals would benefit from their knowledge about the client but that they were not receptive
to non-family members, citing health professionals as being, often dismissive of factual evidence
witnessed and provided by shelter staff supporting the individual.One participant wrote:
Many times I have tried to share information with a hospital only to be told that this information is not as
accurate as the client. Example: a client stated that with the minor surgery they were having, and the
2 days of rest they needed afterwards, that they could stay with a family member. When I explained
that would not be the case as the family member lived in another city and that there was no contact
with them due to the addictions of the client, I was informed that the hospital will allow him to be
discharged to the family home.
For confidentiality reasons, hospital staff may be reluctant to accept information from shelter
workers and are even less inclined to provide information. One participant stated, Even where
there is a care plan in place, the medical profession and particularly the hospitals are not prepared
to share critical information with housing and support provider(s).
Privacy policies were a source of frustration for many participants working in shelters and non-profit
agencies. According to one, Privacy is the main reason given for lack of collaboration with
not-for-profits in the homeless serving sector. Its a cop out, I think. Models exist that show public
health/not-for-profit collaboration can have positive impact on the homeless population.However:
It should also be acknowledged that at times communication from hospital to community
organizations does not occur due to lack of consent from the client. At times the client does not wish to
engage in discharge planning for a number of reasons and that also needs to be respected.
Privacy was identified as a barrier to communication between hospitals and shelters; many felt
that while it has to be respected when requested by the client, the goal should always be to have
consent in place so that information can be freely shared.
Table II Participant agreement
x Median Mode
Hospital discharge planning for patients experiencing homelessness is an issue that needs to be better addressed
in my community 92.88 100 100
Persons experiencing homelessness have unique health care needs 89.14 98 100
Improving hospital discharge planning could help reduce chronic homelessness 82.98 100 100
Persons experiencing homelessness are usually discharged from hospitals to the streets or a shelter 82.67 91 100
Hospitals and homelessness sector agencies work well together to coordinate care 24.33 20 0
Persons experiencing homelessness are well supported in health care settings 22.07 20 0
Persons experiencing homelessness are usually discharged from hospitals with treatment plans that are clear and
easy to follow 17.56 10 0
Persons experiencing homelessness are usually discharged from hospitals into supportive housing 11.09 4 0
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Systems pressures
Each sector has its own pressures that negatively impact their ability to engage in coordinated
discharge planning for persons experiencing homelessness. Hospitals experience the burdens of
being, under so much utilization, wait times and flow pressures; their focus is narrow and the
goal is time and resource efficiency.While some participants noted that, Holding onto patients
for an extra day or two is very helpful,the general consensus from hospital staff was that, we are
not able to keep patients in the hospital just because of housing,and that, there are literally no
free beds in hospitals.As one participant wrote, Often the pressure of making beds freeputs
people in vulnerable situations when they are discharged. Its a broken system and the most
vulnerable people are falling through the cracks.Individuals working within hospitals were equally
frustrated with the lack of beds and pressure to discharge but felt confined by the policies of their
institutions. Individual hospital staff are flexible and patient-centred. It is systemic policies such
as hospital performance measures regarding length of stay that are the barriers.Overcoming the
barriers can require extreme measures, such as one community outreaches nurse who recalled
blocking an unsafe discharge from the ICU, by withholding an electric wheelchair, so the person
had no means of leaving the hospital.Participants stated that Nobody wants to discharge a
patient back to the shelter; it is a terrible situation for everyone involved, especially the patientbut
that, It is not about improving the discharge plan, its (about) changing the policies.
Discharge to shelter was not considered to be a viable option by many participants. For instance,
they stated that Shelter services are not equipped to provide the level of care or support for these
individuals,”“shelter staff are not typically trained in proper after-care or one-to-one care that
many patients needand that to protect their wellness sometimes the only option is, advocating
that the client cannot return to the shelter.Without on-site health care, shelters are rarely a
suitable option for patients with medical needs. What these patients often require is home care
but with no known address, it is virtually impossible to provide.However, just as there are
limited beds in hospitals, There is no housing. You can discharge plan all you want, but waiting
for housing would mean inpatient stays for years and years.The lack of affordable housing was
believed to undermine any efforts at discharge planning. Several participants wrote about the lack
of affordable housing options in Canada as being a crisis. Participants wrote that, People need to
actually transition out of transitional housing; there is no movement in the housing crisis.
Hospital discharge planning is only a small piece of a much larger crisis. There is little in the way
of affordable housing in this city.”“Hospitals can do better to coordinate discharge planning with
shelters, but they cannot fix the crisis. We need access to affordable housing.Pressure is put on
hospital staff to free up beds but the lack of affordable housing stock means that persons
experiencing homelessness have nowhere to go. Accordingly, One can have all the coordinated
efforts they can muster, but if there is no place for people to go, it is a bit like shouting
into the abyss.
The federal decision to withdraw from affordable housing in the 1980s and 1990s has led to an
increase of homelessness in Canada, with current annual figures reaching 235,000 individuals and a
cost of $7.05bn (Gaetz et al., 2013, 2016). At the same time, Canadian hospitals are facing chronic
overcrowding (Ontario Hospital Association, 2018; Zhao et al., 2015) and a 13 percent bed
occupancy rate for patients who are not in need of medical care but lack appropriate referral services
(CIHI, 2010). Furthermore, Canadian research indicates that persons experiencing homelessness
are frequent hospital users (Hwang and Henderson, 2010), contribute to the high cost of health
care provision (Gaetz, 2012; Pomeroy, 2005) and are commonly discharged to shelters or
the street (Pauly, 2014). Given these combinations of factors, the current study sought
to obtain stakeholder opinions on the state of hospital discharge planning for patients
experiencing homelessness.
This paper reported findings from a survey of 660 national stakeholders in Canada. The
research question guiding this investigation was, What are the barriers and system gaps to
timely discharge for people experiencing homelessness from hospital to community in
Canada?Consideration of the scope of the issue was based on knowledge from the
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literature and revealed strong consensus that persons experiencing homelessness have unique
health care needs, improving discharge planning for this population could help reduce chronic
homelessness and persons experiencing homelessness are usually discharged to the
street or a shelter. Results also indicated a strong general consensus that hospitals and
homelessness sector agencies do not work well together to coordinate care, persons
experiencing homelessness are not well supported in health care settings, patients
experiencing homelessness are not usually discharged with plans that are clear and easy to
follow and these individuals are rarely discharged into supportive housing. These findings
support the literature from Canada and the USA that shows individuals experiencing
homelessness often have complex health needs that lead them to seek hospital care (Kushel
et al., 2002; Mackelprang et al., 2014; Tadros et al., 2016), discharge is currently not well
coordinated between hospitals and community supports (Pauly, 2014) and that coordinated
discharge into supportive housing could reduce hospital visits (Raven et al., 2011; Sadowski
et al., 2009) and increase housing security (Forchuk et al., 2006, 2008, 2013).
Analysis of the qualitative data was conducted to identify the current barriers and gaps that
prevent coordinated discharge of patients experiencing homelessness. A general lack of
communication was an issue, particularly with hospital staff not reaching out to agencies; when
communication did occur, it was usually because of the individual staff member being aware of
services and not because of institutional practices. As previously noted, within Canada health
care is a provincial matter but many service providers are municipally funded or not-for-profit.
Working across governments and sectors reduces communication and leads to a lack of
transparency. When communication lacked, the non-profit workers generally felt that claims to
privacy were made. While they supported client-requested privacy, many felt that hospitals used
privacy as a shield for not providing or accepting information about shared clients. Shared
databases in community services have shown that multi-agency information sharing is possible
with proactive consent. Systems integration is increasingly becoming recognized in Canada
(Nichols and Doberstein, 2016) but has been slow to move from theory to practice.
The third barrier identified was the existing system pressure on hospitals, shelters and affordable
housing stock. It is well documented that hospitals in Canada are at- or over- capacity (Zhao
et al., 2015), and that despite the adoption of Housing First (Goering et al., 2014), there are high
rates of homelessness and limited affordable housing (Gaetz et al., 2016). Survey participants
were particularly frustrated with what they described as crisis-level situations, whereby there were
no free beds to keep patients in hospital, limited medically equipped shelters and no housing
options available. These systems pressures meant that individuals had to sometimes undertake
extreme measures, such as withholding a wheelchair at hospital or refusing admission at a
shelter, to prevent early or inappropriate discharge. While participants perceived individuals within
these systems to be client-centered, there was a consensus that the pressures of high demand
and low capacity pervaded hospitals and housing sectors.
Some models of discharge planning, such as direct entry into supportive housing upon
psychiatric discharge, have been effective in Canada (Forchuk et al., 2006, 2008, 2013) but
without more affordable housing stock across the country, the implementation of this method will
be restricted. In the shortage of affordable housing options, medical respite programs (Fader and
Phillips, 2012) may be an alternate option that serve as an intermediary between hospitals and
housing, relieving some of the identified systems pressures. Coordinated discharge checklists,
shown to be effective (Best and Young, 2009), may also improve communication if they are
adapted to be jointly shared across sectors. Effective and sustainable approaches to discharge
for patients experiencing homelessness are possible but will require consideration of
communication, privacy and constraints within the existing systems.
The data were collected through an online survey of national stakeholders. Given its distribution
through the Canadian Observatory on Homelessness, there was likely a self-selection bias, in
which participants who were actively working in homelessness agencies or with persons
experiencing homelessness were more likely to respond. This is supported by the
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high percentage of non-profit workers. Additionally, the survey was predominantly completed in
the province of Ontario and may have had different results if more geographically dispersed.
No patient views were collected in this study.
Within Canada, hospitals and affordable housing are both at full-capacity and working at odds
with one another. The national adoption of Housing First, while having the potential to rapidly
house individuals in need such as those leaving hospitals, is only possible if a sustainable source
of affordable housing exists. Canada is on the verge of another major shift in its approach to
homelessness, reversing the federal devolution of affordable housing with the 2018 National
Housing Strategy (Government of Canada, 2017) and Homelessness Strategy (Government of
Canada, 2018). Reducing the burdens on health care and housing sectors requires that they be
viewed and funded as two interconnected issues and not as parallel systems. As these new
initiatives unfold, Canadian leaders are called upon to invest in affordable housing, as a means of
supporting Housing First and offering a resource for hospital discharge planners. Coordinated
discharge for persons experiencing homelessness would help improve the capacity of
both sectors, but it depends on overcoming the barriers of communication, privacy and
systems pressures.
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Corresponding author
Kristy Buccieri can be contacted at:
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... Furthermore, even when homeless prevention strategies following discharge are put into place, logistical issues, such as hospital policies and measures that prioritize efficiency, eligibility/exclusion criteria, and shelter occupancy rules, act as barriers to people being discharged to an appropriate destination for their care (Jenkinson et al., 2021). Additional barriers include social and economic factors that have formed over time, including cuts to affordable housing, healthcare spending, and social assistance; and municipal governments' overreliance on under-funded homeless services, e.g., shelters (Buccieri, et al., 2018;Jenkinson et al., 2021). ...
Full-text available
The “No Fixed Address” version 2 (NFAv.2) project tested the efficacy of a potential best practice program that aimed to prevent discharge from hospital into homelessness. Forchuk and colleagues developed a system that streamlined housing and social supports using on-site access to help inpatients in a psychiatric unit who were homeless or at-risk of homelessness find safe, affordable housing. A total of 370 individuals accessed the NFAv.2 program between August 2017 and May 2020. Of these, 88 participants who accessed the intervention were enrolled in the evaluation of the project. Information on housing history and housing outcomes were collected during hospital admission and at 3-time points post-discharge. Focus groups were conducted for program participants, health care staff, and community partners to gather information regarding their experiences with the program. Of those who participated in the intervention, 80% were housed and remained housed at 12 months post-discharge. Results from focus groups also indicated that the majority of NFAv.2 clients, staff, and community partners were satisfied with the intervention. Since homelessness has a detrimental effect on recovery, client safety, and healthcare expenditures, locating safe housing has had a positive impact on treatment, rehabilitation, and the healthcare system as a whole. The findings of this project offer policy alternatives for the prevention of homelessness for at-risk individuals.
... To this end, researchers have developed a typology of homelessness prevention that can be put into practice, incorporating structural, systems, early intervention, evictions prevention, and housing stabilization elements (Dej et al., 2020). Key to prevention efforts, and as outlined by the researchers in this study, is a focus on discharge (Buccieri et al., 2018) and systems alignment (Buchnea et al., 2021;Nichols & Doberstein, 2016), such as between affordable housing and institutions such as hospitals, corrections, and child welfare. However, political will is essential for moving the needle on homelessness prevention (Szeintuch, 2017). ...
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Ten-year plans to end homelessness have become common in communities across Canada, yet homelessness persists. This study brings together experts in the field of homelessness to gain insight into whether homelessness can be ended and what steps need to be taken to accomplish this. Twenty-six Canadian homelessness researchers participated in video-recorded structured interviews in the summer of 2021. They were asked whether, and how, homelessness could be ended in Canada. Interviews were transcribed and analyzed for recurring themes. There was widespread agreement across the participants that homelessness could be ended in Canada by focusing on four distinct yet related areas. First, all levels of government must be held accountable for policy decisions they make, and they must learn from other countries, such as Finland, where social welfare policies are more robustly integrated. Second, Canada must continue to implement policies and laws that prioritize housing as a human right rather than a commodity. Third, there is a need for individualized choice-based supports, following the principles of Housing First, which emphasize community integration. Finally, preventive measures must be prioritized with a focus on improved systems alignment and discharge planning between institutions. This paper does not offer a blueprint for change, recognizing the extent of public and social policies, tax restructuring, and ideological shifts that will need to occur. Rather, it provides a thoughtful reflection from researchers on where we as a nation should focus our attention if we want to end homelessness in Canada.
... Many scholars note how marginalized populations such as those experiencing homelessness are both vulnerable to, and disproportionately affected by, the COVID-19 pandemic and resulting policies to control the spread of the virus (Buccieri et al., 2018;Culhane et al., 2020;Lima et al., 2020;Martin et al., 2021;Perri et al., 2020;Schiff et al., 2020). Participants who experienced homelessness explained how for the most part, COVID-19 amplified the suffering of being homeless. ...
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Expanding the emergent literature on homelessness and the COVID-19 pandemic, this qualitative study presents a portrait of the homelessness sector in two Nova Scotian, Canadian communities: Halifax Regional Municipality and Cape Breton Regional Municipality. This research provides an understanding of the health and wellness of populations experiencing homelessness during the first waves of the COVID-19 pandemic, the processes involved in supporting populations experiencing homelessness during the pandemic, and determining what has worked, what has not, and required changes. The data will inform relevant emergency crises and disaster relief responses for those experiencing homelessness and those who are marginalized, vulnerable, and living on the fringes of society. What follows are the core themes, and lessons learned, along with recommendations that capture the narratives from a group of individuals experiencing homelessness throughout the pandemic and those tasked with developing, supporting, innovating, and funding the disaster responses in two Nova Scotian communities.
... Systems failures are unfortunately common in the homelessness literature, including hospital discharge from acute mental health care (Forchuk et al., 2013b) and research that focuses on post-discharge care (Buccieri et al., 2018;Canham, Davidson, et al., 2019), youth homelessness (Nichols, 2016), unhoused individuals with disabilities (Collins, Schormans, Watt, Idems, & Wilson, 2018), and unhoused patients with mental illness (Stergiopoulos et al., 2017. Combined, these studies suggest that it is important to dismantle sectoral silos that impinge equitable access to care for individuals living unhoused, including during the discharge process (Clapton, Chenoweth, McAuliffe, Clements, & Perry, 2014), and address improvements to the discharge process as part of an interconnected web of service provision. ...
Full-text available
Hospital discharge is a key transition in a patient's care pathway, providing an effective point of intervention to address a patient's ongoing health and social care needs. Addressing these needs may prevent hospital readmissions. The hospital discharge process for people experiencing homelessness who have been admitted for medical conditions has not been well-characterized. To address this gap in knowledge, we interviewed hospital and shelter workers, and key informants, about their experiences when unhoused patients are discharged from hospitals to shelters. Using critical realism, we explored the organizational and service context of this process by looking at the relationship between structures and agency in the daily work of our participants. Our results indicate that the discharge process for unhoused patients was shaped by two systems failures, barriers to publicly funded systems including community resources, and silos and gaps between these systems, ultimately leading to failed transitions to the community. The most prominent manifestations of these systems failures were a) limited and inadequate access to post-discharge care and services, b) barriers to accessing shelters, c) inadequate service integration between healthcare and social service sectors, and, d) poor cross-sectoral knowledge between hospital and shelter workers. We characterize the discharge process for unhoused patients as a part of a larger systems failure in the care for unhoused patients and contend that improvements in hospital discharges requires changes to underlying structures that lead to inadequate discharges.
... Less research focuses on discharge after hospitalization for physical health conditions, despite frequent admissions and long lengths of stay for homeless patients admitted to medical and surgical services (Hwang et al., 2011). A small number of studies have described barriers or challenges to discharging homeless patients from acute care (e.g., Buccieri et al., 2018), but are not explicit on why and how these challenges exist. We seek to add to current knowledge by providing further explanations for how and why discharging homeless patients from general medicine to an appropriate discharge destination remains challenging. ...
Objectives A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts. Methods Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare. Results Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging. Conclusion Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.
Full-text available
Background Establishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum. Methods We performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process. Results The findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care. Conclusions We emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.
It is well-known that people with psychiatric diagnoses experience disproportionate rates of homelessness. However, few studies have explored the perspectives and practices of mental health social workers in responding to clients experiencing homelessness. This article reports on findings from three focus groups with inpatient mental health social workers in Sydney, Australia. Three themes were identified: stuck in a crisis; reliance on sub-standard housing conditions; and pressures to discharge. The study reveals the challenges experienced by social workers in navigating scarce housing resources, and the limitations of a biomedical paradigm in failing to address the social determinants of mental distress.
Homelessness is a long-standing issue at the forefront of healthcare globally, and discharge of homeless patients from hospital settings can exacerbate gaps and burdens in healthcare systems. In hospitals, social workers often take on the majority of responsibility for facilitating patient discharge transitions out of hospital care. Research in this area to date has explored experiences and outcomes of homeless clients, and the experiences of social workers in these roles are not well known. The current study's objective was to elucidate observations and experiences of hospital social workers who discharge patients into homelessness. A total of 112 social workers responded to an online questionnaire, and responses to open-ended questions were analyzed for thematic content. Four overarching themes emerged: (1) complexity of clients, (2) systemic barriers, (3) resource gaps, and (4) negative impact on social workers. It is clear that significant change is required to address the multitude of challenges that intersect to reinforce health inequities. Results can be used by social workers, health authorities, community providers, researchers, and policymakers in discussions about best practices for homeless clients.
Full-text available
Background In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home. Methods The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes ( n = 5) and those with no specialist discharge scheme (standard care) ( n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages. Results There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding. Strengths and limitations To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care). Future work There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.
Full-text available
Homelessness is a systemic problem involving numerous sectors, institutions and agencies and, therefore, requires more integrated system responses in terms of governance, policy and programs. The widespread homelessness experienced in our communities indeed reveals deep structural inequities in our economy and society that ought to be addressed, but also represents a systematic governance failure characterized by a lack of ownership of this issue in and across government. The growing scholarly and practitioner movement towards systems integration thus refers to strategies and frameworks to improve collaboration and coordination between people, organizations and sectors that touch upon homelessness, including some that may not conceive of themselves as directly related to the issue.
Full-text available
This review presents a realist synthesis of “what works and why” in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the “Homeless Hospital Discharge Fund”). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe “interventions” that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of “thick description”. The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that “psychologically informed” approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not “handed over” at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.
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Gender non-conforming and sexual minority youth are overrepresented in the homeless youth population and are frequently discriminated against in shelters and youth serving organizations. This paper provides a contextual understanding of the ways that institutional and governmental policies and standards often perpetuate the social exclusion of lesbian, gay, bisexual, transgender, queer, and 2-Spirit (LGBTQ2S) youth, by further oppression and marginalization. Factors, including institutional erasure, homophobic and transphobic violence, and discrimination that is rarely dealt with, addressed, or even noticed by shelter workers, make it especially difficult for LGBTQ2S youth experiencing homelessness to access support services, resulting in a situation where they feel safer on the streets than in shelters and housing programs. This paper draws on data from a qualitative Critical Action Research study that investigated the experiences of a group of LGBTQ2S homeless youth and the perspectives of staff in shelters through one-on-one interviews in Toronto, Canada. One of the main recommendations of the study included the need for governmental policy to address LGBTQ2S youth homelessness. A case study is shared to illustrate how the Government of Alberta has put this recommendation into practice by prioritizing LGBTQ2S youth homelessness in their provincial plan to end youth homelessness. The case study draws on informal and formal data, including group activities, questions, and surveys that were collected during a symposium on LGBTQ2S youth homelessness. This paper provides an overview of a current political, social justice, and public health concern, and contributes knowledge to an under researched field of study by highlighting concrete ways to prevent, reduce, and end LGBTQ2S youth homelessness.
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Background Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. This article describes the rationale for a brief case management intervention for frequent ED users with mental health and/or addiction challenges and the design of a randomized trial assessing its effectiveness. Methods/DesignEligible participants are adults in a large urban centre with five or more ED visits in the past year, with at least one prior visit for a mental health or addictions reason. Participants (N = 166) will be randomized to either 4 to 6 months of brief case management or usual care, and interviewed every 3 months for 1 year. Consent will be sought to access administrative health records. A subset of participants (N = 20) and service providers (N = 13) will participate in qualitative data collection. DiscussionAddressing the needs of frequent ED users is a priority in many jurisdictions. This study will provide evidence on the effectiveness of brief case management, compared to usual care, on reducing ED visits among frequent ED users experiencing mental health or substance misuse problems, and inform policy and practice in this important area. Trial Identifier: NCT01622244. Registered 4 June 2012.
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Homelessness is a complex social issue that requires a coordinated systems approach. In recent years, Canada has seen an emergence of integrated care, the joining of health care and social care, to address the needs of homeless persons. This article documents the findings of open-ended interviews with eleven members of the central east Ontario Housing and Homelessness Framework Steering Committee, comprised of service managers and the Local Health Integration Network. As the system planners for social housing and health care, respectively, members of the group work together to align system approaches for homeless persons. Research by this group identified three challenges of collaborating-their different histories and legislation, varied accountability structures, and differing roles and responsibilities within the central east region of Ontario. The study findings indicate that developing a joint document to guide the work was a process through which members began to work through these differences.
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Background: Homelessness is associated with a very high prevalence of substance use and mental disorders and elevated levels of acute health service use. Among the homeless, little is known regarding the relative impact of specific mental disorders on healthcare utilization. The aim of the present study was to examine the association between different categories of diagnosed mental disorders with hospital admission and length of stay (LOS) in a cohort of homeless adults in Vancouver, Canada. Methods: Participants were recruited as part of an experimental trial in which participants met criteria for both homelessness and mental illness. Administrative data were obtained (with separate consent) including comprehensive records of acute hospitalizations during the 10 years prior to recruitment and while participants where experiencing homelessness. Generalized Estimating Equations were used to estimate the associations between outcome variables (acute hospital admissions and LOS) and predictor variables (specific disorders). Results: Among the eligible sample (n = 433) 80 % were hospitalized, with an average of 6.0 hospital admissions and 71.4 days per person during the 10-year observation period. Of a combined total 2601 admissions to hospital, 1982 were psychiatric and 619 were non-psychiatric. Significant (p <0.001) independent predictors of hospital admission and LOS included a diagnosis of schizophrenia or bipolar disorder, as well as high (≥32 service contacts) non-psychiatric medical service use in the community. Conclusions: Our results demonstrate that specific mental disorders alongside high non-psychiatric service use were significantly associated with hospital admission and LOS. These findings suggest the importance of screening within the homeless population to identify individuals who may be at risk for acute illness and the implementation of services to promote recovery and prevent repeated hospitalization. Trial registration: ISRCTN57595077 ; ISRCTN66721740.
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Purpose – The purpose of this paper is to introduce a method of the bottleneck detection for Emergency Department (ED) improvement using benchmarking and design of experiments (DOE) in simulation model. Design/methodology/approach – Four procedures of treatments are used to represent ED activities of the patient flow. Simulation modeling is applied as a cost-effective tool to analyze the ED operation. Benchmarking provides the achievable goal for the improvement. DOE speeds up the process of bottleneck search. Findings – It is identified that the long waiting time is accumulated by previous arrival patients waiting for treatment in the ED. Comparing the processing time of each treatment procedure with the benchmark reveals that increasing the treatment time mainly happens in treatment in progress and emergency room holding (ERH) procedures. It also indicates that the to be admitted time caused by the transfer delay is a common case. Research limitations/implications – The current research is conducted in the ED only. Activities in the ERH require a close cooperation of several medical teams to complete patients’ condition evaluations. The current model may be extended to the related medical units to improve the model detail. Practical implications – ED overcrowding is an increasingly significant public healthcare problem. Bottlenecks that affect ED overcrowding have to be detected to improve the patient flow. Originality/value – Integration of benchmarking and DOE in simulation modeling proposed in this research shows the promise in time-saving for bottleneck detection of ED operations.
Background: A 2005 study examined emergency department (ED) utilization by homeless patients in the United States. Within the following 5 years, unemployment increased by 5%. Objective: The objective was to analyze changes in ED utilization between 2005 and 2010 by homeless patients and compare with nonhomeless visits. Methods: Data from the 2010 National Hospital Ambulatory Medical Care Survey were evaluated. Results: Approximately 679854 visits were made by homeless patients, the majority of which were made by men (72.3%) and patients between the ages of 45 and 64 (50.5%). Homeless patients were twice as likely to be uninsured. ED visits by homeless patients had increased by 44% during the 5-year period. Arrival to the ED by ambulance increased by 14% between the study years, and homeless patients were less likely to be admitted. Conclusion: The number of visits by homeless patients in the ED increased proportionally to an overall increase in ED visits between 2005 and 2010.
The present study assessed the effects of an intervention that was designed to provide on-site, predischarge housing assistance for psychiatric clients. Participants included clients from acute (n = 219) and tertiary (n = 32) care hospital sites. Data were collected from hospital and shelter databases. Results revealed that in the majority of cases, the intervention reduced the number of individuals discharged to homelessness or no fixed address. In addition, the costs of implementing and maintaining the intervention were less than the increased medical costs associated with homelessness and housing individuals in shelters.