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Hospital discharge planning for Canadians experiencing homelessness

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Abstract

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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To cite this document:
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://
doi.org/10.1108/HCS-07-2018-0015
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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
Abstract
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
j
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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?
Methodology
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.
Findings
Demographics
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.
Communication
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.
Privacy
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.
Discussion
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.
Limitations
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.
Conclusion
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.
References
Abramovich, A. (2016), Preventing, reducing, and ending LGBTQ2S youth homelessness: the need for
targeted strategies,Social Inclusion, Vol. 4 No. 4, pp. 86-96.
Backer, T.E., Howard, E.A. and Moran, G.E. (2007), The role of effective discharge planning in preventing
homelessness,Journal of Primary Prevention, Vol. 28 Nos 3-4, pp. 229-43.
Best, J.A. and Young, A. (2009), A SAFE DC: a conceptual framework for care of the homeless inpatient,
Journal of Hospital Medicine, Vol. 4 No. 6, pp. 375-81.
Buccieri, K. (2016), Integrated health and housing care for homeless and marginally housed individuals: a
study of the housing and homelessness steering committee in Ontario, Canada,Social Sciences, Vol. 5
No. 2, p. 15.
Calgary Homeless Foundation (2014), System Planning Framework, Calgary Homeless Foundation, Calgary.
CIHI (2010), Health Care in Canada 2010: Evidence of Progress, But Care Not Always Appropriate, Canadian
Institute for Health Information, Ottawa.
Cornes, M., Whiteford, M., Manthorpe, J., Neale, J., Byng, R., Hewett, N., Clark, M., Kilmister, A., Fuller, J.,
Aldridge, R. and Tinelli, M. (2017), Improving hospital discharge arrangements for people who are homeless:
a realist synthesis of the intermediate care literature,Health and Social Care in the Community, Vol. 26 No. 3,
pp. 345-59.
Doran, K.M., Curry, L.A., Vashi, A.A., Platis, S., Rowe, M., Gang, M. and Vaca, F.E. (2014), “‘Rewarding and
challenging at the same time: emergency medicine residentsexperiences caring for patients who are
homeless,Academic Emergency Medicine, Vol. 21 No. 6, pp. 673-9.
Fader, H. and Phillips, C. (2012), Frequent-user patients: reducing costs while making appropriate
discharges,Healthcare Financial Management, Vol. 66 No. 3, pp. 98-100.
Fazel, S., Geddes, J.R. and Kushel, M. (2014), The health of homeless people in high-income countries:
descriptive epidemiology, health consequences, and clinical and policy recommendations,The Lancet,
Vol. 384 No. 9953, pp. 1529-40.
Forchuk, C., Russell, G., Kingston-MacClure, S., Turner, K. and Dill, S. (2006), From psychiatric ward to the
streets and shelters,Journal of Psychiatric and Mental Health Nursing, Vol. 13 No. 3, pp. 301-8.
Forchuk, C., MacClure, S.K., Van Beers, M., Smith, C., Csiernik, R., Hoch, J. and Jensen, E. (2008),
Developing and testing an intervention to prevent homelessness among individuals discharged from
psychiatric wards to shelters and no fixed address’”,Journal of Psychiatric and Mental Health Nursing,
Vol. 15 No. 7, pp. 569-75.
HOUSING, CARE AND SUPPORT
Downloaded by Doctor Kristy Buccieri At 12:20 20 November 2018 (PT)
Forchuk, C., Godin, M., Hoch, J.S., Kingston-MacClure, S., Jeng, M.S., Puddy, L., Vann, R. and Jensen, E.
(2013), Preventing psychiatric discharge to homelessness,Canadian Journal of Community Mental Health,
Vol. 32 No. 3, pp. 17-28.
Forster, A.J., Stiell, I., Wells, G., Lee, A.J. and Van Walraven, C. (2003), The effect of hospital occupancy on
emergency department length of stay and patient disposition,Academic Emergency Medicine, Vol. 10 No. 2,
pp. 127-33.
Gaetz, S. (2010), The struggle to end homelessness in Canada: how we created the crisis, and how we can
end it,The Open Health Services and Policy Journal, Vol. 3 No. 2, pp. 21-6.
Gaetz, S. (2012), The Real Cost of Homelessness: Can we Save Money by Doing the Right Thing?, Canadian
Homelessness Research Network Press, Toronto.
Gaetz, S., Dej, E., Richter, T. and Redman, M. (2016), The State of Homelessness in Canada 2016, Canadian
Observatory on Homelessness Press, Toronto.
Gaetz, S., Donaldson, J., Richter, T. and Gulliver, T. (2013), The State of Homelessness in Canada 2013,
Canadian Homelessness Research Network Press, Toronto.
Goering, P., Veldhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E. and Aubry, T. (2014), National Final
Report: Cross-Site at Home/Chez Soi Project, Mental Health Commission of Canada, Calgary.
Government of Canada (2017), A Place to Call Home: Canadas National Housing Strategy, Government of
Canada, Ottawa.
Government of Canada (2018), Reaching Home: Canadas Homelessness Strategy, Government of
Canada, Ottawa.
Greysen, S.R., Allen, R., Rosenthal, M.S., Lucas, G.I. and Wang, E.A. (2013), Improving the quality of
discharge care for the homeless: a patient-centered approach,Journal of Health Care for the Poor and
Underserved, Vol. 24 No. 2, pp. 444-55.
Guba, E.G. and Lincoln, Y. (1989), Fourth Generation Evaluation, Sage, Newbury Park, CA.
Hewett, N. (2013), Closing the Gap through Changing Relationships: Final Report for Closing the Gap through
Changing Relationships, The London Pathway, London.
Hwang, S.W. and Henderson, M. (2010), Health Care Utilization in Homeless People: Translating Research
into Policy and Practice, Agency for Healthcare Research & Quality, Rockville, MD.
Hwang, S.W.,Weaver, J., Aubry, T. and Hoch, J.S. (2011), Hospital costs and length of stay among homeless
patients admitted to medical, surgical, and psychiatric services,Medical Care, Vol. 49 No. 4, pp. 350-4.
Hwang, S.W., Chambers, C., Chiu, S., Katic, M., Kiss, A., Redelmeier, D.A. and Levinson, W. (2013),
A comprehensive assessment of health care utilization among homeless adults under a system of universal
health insurance,American Journal of Public Health, Vol. 103 No. S2, pp. S294-301.
Kripalani,S., Jackson,A.T., Schnipper, J.L. and Coleman, E.A. (2007), Promoting effective transitions of care at
hospital discharge: a review of key issues for hospitals,Journal of Hospital Medicine, Vol. 2 No. 5, pp. 314-23.
Kushel, M.B., Perry, S., Bangsberg, D., Clark, R. and Moss, A. (2002), Emergency department use among
the homeless and marginally housed: results from a community-based study,American Journal of Public
Health, Vol. 92 No. 5, pp. 778-84.
Mackelprang, J.L., Graves, J.M. and Rivara, F.P. (2014), Homeless in America: injuries treated in US emergency
departments 20072011,International Journal of Injury Control and Safety Promotion, Vol. 21 No. 3, pp. 289-97.
Mikkonen, J. and Raphael, D. (2010), Social Determinants of Health: The Canadian Facts, York University
School of Health Policy and Management, Toronto.
Moore, G., Gerdtz, M., Hepworth, G. and Manias, E. (2010), Homelessness: patterns of emergency
department use and risk factors for re-presentation,Emergency Medicine Journal, Vol. 28 No. 5, pp. 422-7.
Nichols, N. and Doberstein, C. (Eds) (2016), Exploring Effective Systems Responses to Homelessness,
Canadian Observatory on Homelessness Press, Toronto.
Ontario Hospital Association (2018), A sector on the brink: the case for a significant investment in Ontarios
hospitals, available at: www.oha.com/Bulletins/2558_OHA_A%20Sector%20on%20the%20Brink_rev.pdf
(accessed July 18, 2018).
HOUSING, CARE AND SUPPORT
Downloaded by Doctor Kristy Buccieri At 12:20 20 November 2018 (PT)
Padgett, D., Henwood, B.F. and Tsemberis, S.J. (2016), Housing First: Ending Homelessness, Transforming
Systems and Changing Lives, Oxford University Press, New York, NY.
Pauly, B. (2014), Close to the street: nursing practice with people marginalized by homelessness and
substance use, in Guirguis-Younger, M., McNeil, R. and Hwang, S.W. (Eds), Homelessness and Health in
Canada, University of Ottawa Press, Ottawa, pp. 211-32.
Pomeroy, S. (2005), The Cost of Homelessness: Analysis of Alternate Responses in Four Canadian Cities,
National Secretariat on Homelessness, Ottawa.
Powell, L. and Hewett, N. (2011), Pathway Needs Assessment at Brighton and Sussex University Hospital,
The London Pathway, London.
Raven, M.C., Doran, K.M., Kostrowski, S., Gillespie, C.C. and Elbel, B.D. (2011), An intervention to improve
care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study,BMC Health
Services Research, Vol. 11, p. 270.
Russolillo, A., Moniruzzaman, A., Parpouchi, M., Currie, L.B. and Somers, J.M. (2016), A 10-year
retrospective analysis of hospital admissions and length of stay among a cohort of homeless adults in
Vancouver, Canada,BMC Health Services Research, Vol. 16 No. 1, p. 60.
Sadowski, L., Romina, K., VanderWeele, T. and Buchanan, D. (2009), Effect of a housing and case
management program on emergency department visits and hospitalizations among chronically ill homeless
adults,JAMA, Vol. 301 No. 17, pp. 1771-8.
Stergiopoulos, V., Gozdzik, A., Tan de Bibiana, J., Guimond, T., Hwang, S.W., Wasylenki, D.A. and Leszcz,
M. (2016), Brief case management versus usual care for frequent users of emergency departments: the
coordinated access to care from hospital emergency departments (CATCH-ED) randomized control trial,
BMC Health Services Research, Vol. 16 No. 1, p. 432.
Strunin, L., Stone, M. and Jack, B. (2007), Understanding rehospitalization risk: can hospital discharge be
modified to reduce recurrent hospitalization,Journal of Hospital Medicine, Vol. 2 No. 5, pp. 297-304.
Tadros, A., Layman, S.M., Pantaleone Brewer, M. and Davis, S.M. (2016), A 5-year comparison of ED visits
by homeless and nonhomeless patients,American Journal of Emergency Medicine, Vol. 34 No. 5, pp. 805-8.
Wen, C.K., Hudak, P.L. and Hwang, S.W. (2007), Homeless peoples perceptions of welcomeness and
unwelcomeness in healthcare encounters,Journal of the Society of General Internal Medicine, Vol. 22 No. 7,
pp. 1011-7.
Zhao, Y., Peng, Q., Strome, T., Weldon, E., Zhang, M. and Chochinov, A. (2015), Bottleneck detection for
improvement of emergency department efficiency,Business Process Management Journal, Vol. 21 No. 3,
pp. 564-85.
Corresponding author
Kristy Buccieri can be contacted at: kristybuccieri@trentu.ca
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... A key area of concern that has been identified within the health care sector is discharge planning. Discharge from hospital to homelessness can occur throughout the health care system (Buccieri et al. 2018). It can be the case where an individual has entered into hospital from homelessness and is returning to homelessness, it can also be a case where an individual has lost access to their housing during their hospital stay. ...
... Discharge to no fixed address is a controversial practice that has been researched fairly extensively (Buccieri et al. 2018). Of little surprise is that policies that prevent discharge to no fixed address lead to better long-term housing outcomes (Forchuk et al. 2013). ...
... Instead, linking the health sector into shared databases and coordinated access is a more promising next step. As noted by Buccieri et al. (2018), where the goal is to discharge people from the hospital into housing, the limitation is availability of or knowledge of housing options. Therefore, policy can serve to bridge this gap. ...
Chapter
Full-text available
Homelessness is often considered to be an outcome of individual behaviours and shortcomings, or individual conditions. However, research has demonstrated that there are several policy factors that are strong predictors of homelessness at state or national levels. In fact, policies from sectors as various as the justice system, health system, income supports, and housing can all create the context in which people find themselves de-housed. This chapter will explore homelessness as a “fusion policy problem”, meaning that problems across a variety of policy areas fuse together to create this particular social ill. The chapter focuses on the U.S., Canada, and Finland as examples, although the concept holds true internationally. A variety of particularly concerning policies is presented across different public systems, and proposed reforms to each of the policies are presented from within the research literature. Ultimately, this chapter presents considerations for how we can prevent and end homelessness at a structural rather than individual level.
... Documented challenges in the discharge process include poor communication and collaboration among and between community and hospital care providers (Kripalani et al., 2007;McKenna et al., 2000;Nordmark et al., 2016), and poor communication and knowledge sharing between hospitals and social service agencies (Buccieri et al., 2019). Knowledge sharing is a key part of the discharge process (Cameron et al., 2014;Glasby, 2003;Kripalani et al., 2007;Waring et al., 2014), and barriers to knowledge sharing between hospitals and discharge destinations can cause adverse events (Hesselink et al., 2014), unsafe discharges (Buccieri et al., 2019) and breakdowns in continuity of care (Nordmark et al., 2016). ...
... Documented challenges in the discharge process include poor communication and collaboration among and between community and hospital care providers (Kripalani et al., 2007;McKenna et al., 2000;Nordmark et al., 2016), and poor communication and knowledge sharing between hospitals and social service agencies (Buccieri et al., 2019). Knowledge sharing is a key part of the discharge process (Cameron et al., 2014;Glasby, 2003;Kripalani et al., 2007;Waring et al., 2014), and barriers to knowledge sharing between hospitals and discharge destinations can cause adverse events (Hesselink et al., 2014), unsafe discharges (Buccieri et al., 2019) and breakdowns in continuity of care (Nordmark et al., 2016). Discharge conversations when transitioning from hospital to home are crucial (including shelters) (Kiran et al., 2019), but shelter workers are often left out of these conversations due to patient privacy and confidentiality concerns (Buccieri et al., 2019). ...
... Knowledge sharing is a key part of the discharge process (Cameron et al., 2014;Glasby, 2003;Kripalani et al., 2007;Waring et al., 2014), and barriers to knowledge sharing between hospitals and discharge destinations can cause adverse events (Hesselink et al., 2014), unsafe discharges (Buccieri et al., 2019) and breakdowns in continuity of care (Nordmark et al., 2016). Discharge conversations when transitioning from hospital to home are crucial (including shelters) (Kiran et al., 2019), but shelter workers are often left out of these conversations due to patient privacy and confidentiality concerns (Buccieri et al., 2019). ...
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People experiencing homelessness use acute healthcare at higher rates than the general population, yet hospitals frequently discharge them to the streets or emergency shelters. Available literature on the hospital discharge process for people experiencing homelessness identifies knowledge sharing as an important and challenging part of the discharge process; however, it does little to explain what generates these challenges or what might support knowledge sharing. In this study, we explain under which contexts certain mechanisms are triggered to facilitate knowledge sharing between hospitals and shelters during the discharge process. Between September 2018 and April 2019, we interviewed 33 participants: hospital workers on general medicine wards across three hospitals; shelter workers; researchers, policy advisors or advocates working at the intersection of homelessness and healthcare in Toronto. We find that within the legal context of health information protection, the concept of "circle of care" has created barriers to knowledge sharing between hospitals and shelters by excluding shelter workers from discharge planning. We note, however, that the degree to which hospital workers have navigated these barriers and brought shelter workers into the discharge process varies across hospitals. We explore this variation and find that certain geographic and organisational contexts have activated the development of institutional-and individual-level relationships between hospitals and shelters or their workers, respectively. We suggest that these relationships generate increased trust and communication and have led to knowledge sharing between hospitals and shelters. These findings are applicable in most urban centres with hospitals and where people experiencing homelessness live. Understanding the role of context is imperative for developing appropriate and effective interventions to improve hospital discharge processes. The development and implementation of more effective discharge processes can contribute to improved post-discharge care and recovery for this patient population and contribute to addressing health equity. K E Y W O R D S context, critical realism, homelessness, hospital discharge, knowledge sharing
... 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. ...
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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. ...
Article
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... Housing is a key social determinant of health, and it is widely documented that homeless people (including hidden homeless/housing-insecure individuals) suffer from much poorer health status and health outcomes than the general population (Frankish et al. 2005(Frankish et al. , 2009Hwang et al. 2009). These medical-and health-related issues combine with social exclusion to create particularly significant vulnerability to infectious disease transmission and recovery (Buccieri et al. 2018). The homelessness response system has historically been focused on emergency response. ...
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Addressing the vulnerability and unique needs of homeless populations during pandemics has been a major component of the Canadian federal response to the COVID-19 crisis. Rural and remote communities, however, have received little to no funding to aid in their care of homeless people during the pandemic. Similarly, there has been little to no research on rural communities' pandemic preparedness in the context of homelessness. There are large numbers of homeless individuals in rural and remote Canada, including Indigenous peoples who are over-represented in homeless populations. Rural communities, including rural and remote Indigenous communities, are often isolated and more limited than urban areas in their capacity to respond to pandemics. They are particularly vulnerable due to fewer healthcare and social service resources-the lack of which has been particularly evident during the COVID-19 pandemic. In this commentary, we suggest that policy-makers need to take seriously the situation of rural homelessness in Canada, its implications for individual and community health, and consequences in the context of pandemics. Policy- and decision-makers can address these concerns through increased homelessness funding and support for rural and remote communities, policy change to recognize the unique challenges associated with rural pandemic planning and homelessness, and more research that can be translated into policy, programs, and supports for rural homelessness and pandemic planning response.
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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.
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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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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.
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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: 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.
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