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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://
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 28–34 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 Canada’s 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 Foundation’s(2014)“systems of care”planning, 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
Canada’s 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, Canada’s 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 community”through 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 0–100, 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 0–100, 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 services”and 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 0–5 214 34.9
Yukon 2 0.3 6–10 175 28.6
Northwest Territories 1 0.2 11–20 127 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 don’t agree with the changes and won’t 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. It’s 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 free’puts
people in vulnerable situations when they are discharged. It’s 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 patient”but
that, “It is not about improving the discharge plan, it’s (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 need”and 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.
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Corresponding author
Kristy Buccieri can be contacted at: kristybuccieri@trentu.ca
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