As I embarked on this first course in my Master of Health Studies, I thought I had a good grasp of the role played by an acute care hospital within the larger Provincial and Federal health care system. After examining the definition of health, learning about the social determinants of health and vulnerable populations, thinking about a multi level model of health, and learning about the impact and rate of chronic illness, I am not as sure. My current position is responsible for the patient flow through the acute care system. I am largely responsible to oversee timely access to an inpatient hospital bed for all patients. This requires a steady flow of discharges to ensure bed availability. Sounds simple right? Not at all! Canada has the highest rate of emergency room utilization among industrialized countries and many of these visits are for issues that could have been addressed in the doctor’s office (Roberge et. al., 2010). Another issue impacting hospital congestion is those patients that stay in hospital after their medical need has been met and no longer need the services of an acute care hospital. The Canadian Institute for Health Information (CIHI) categorizes these patients as needing alternate level of care (ALC) and estimates that 13% of acute care beds in Canada are occupied by patients in this category considered well enough to discharge (2009). The blocking of beds by patients medically well enough for discharge adds to hospital congestion issues.
Looking at health more widely throughout this course has me thinking. Is the goal of a hospital stay to achieve health or is it merely to seek treatment for a sudden illness? CIHI (n.d.) acknowledges the important role that acute inpatient hospitals play in the continuum of healthcare services in Canada. CIHI lists the purpose of acute care hospitals as providing “necessary treatment for a disease or severe episode of illness for a short period of time. The goal is to discharge patients as soon as they are healthy and stable.” So, what is healthy? In 1948, the World Health Organization (WHO) defined health to be a state of complete social, physical, and mental well being however this definition is felt to be outdated and unachievable by most people (Smith, 2008). There are several expanded definitions of health that look at the interplay between the person and their environment and social support system. Some definitions expand further to discuss that the meaning of health is different to every individual and speaks to a person’s ability to adapt to their circumstances (The Lancet, 2009). If we want fewer hospitalizations, it makes sense that we need to increase the health of the population but is acute care hospital the place to achieve this?
There is one vulnerable population where high emergency room utilization rates and ALC categorization are common – those who are homeless. In this post, we will take a closer look at the relationship between those who are homeless and healthcare and make suggestions for the future of healthcare for this population. The 2018 Report on Homeless Counts in BC estimates that 7655 people in the province of British Columbia are experiencing homelessness and that more than half of these people have two or more health conditions.
Figure 1
Note: 2018 Report of Homeless Counts in BC. Data represents numbers and health of homeless people in BC resulting from 24 counts completed in 2017/2018.
The health of an individual is multi factorial. The WHO (n.d.) defines the social determinants of health as the nonmedical factors that impact and shape our health in both positive and negative ways and contribute to health inequality. Housing or lack there of is a social determinant of health that impacts the conditions in which an individual lives, grows and ages (WHO, n.d.). Individuals who are homeless often have less income, food instability, lower education, less social support, and lack a primary care provider. The combination of these social determinants of health has a much larger impact on the health of an individual than the health care system itself (WHO, n.d.).
Figure 2
Note: A pictorial representation by Adhikari (2017) of the social determinants of health as a complex, interrelated system that impacts health incomes.
People who are homeless often suffer from chronic illness at rates that are higher than comparison groups in the same age and gender categories and experience higher mortality than those with stable housing (Jaworsky et. al., 2016). Jaworsky et. al. (2016) examined the association between housing stability, unmet medical needs and emergency department utilization in 3 large Canadian cities: Vancouver, Toronto, and Ottawa. They found that those who were homeless often postponed needed health care and had their physical health needs go unmet. Khandor et. al. (2013) found that less than half of homeless individuals have a family doctor and that the odds of having a family physician decreased with every year the individual spends homeless. They also found that twenty-nine percent of homeless individuals had no usual source of healthcare. This may explain why Jaworsky et. al. found that the rate of emergency room use was much higher when an individual was homeless. Jaworsky et. al. discovered that even when those who are homeless have access to free primary care that emergency use was higher in this population. The authors wondered if this was related to stigma and discrimination, the location of the services or transportation and recommended more research to fully understand why. One study, by Skosireva et. al. (2014) found a high prevalence of perceived discrimination in healthcare settings in Canada due to homelessness and found that this discrimination increased the longer the individual had been homeless. This discrimination may impact whether a homeless individual feels comfortable enough to seek healthcare.
Once a homeless individual has recovered from their acute medical issue their discharge from hospital is often delayed due to a lack of a safe discharge environment. Feigal et. al. (2014) found that homeless individuals spend approximately 4 more days in hospital than housed individuals hospitalized for the same medical reason. Feigal et. al. notes that often the individual is too frail to recover on the street and therefore discharge from hospital is delayed. Park et. al. (2017) notes that post discharge locations such as shelters are unable to provide an environment that allows for resting, medication administration or other follow up treatments and often do not allow for stays longer than twenty-four hours. CIHI (2009) found that individuals who are deemed ALC spend an additional 7 days in hospital, with 20% of patients in this category staying longer than a month. The average cost of housing a homeless individual in hospital is $10, 900 per month and costs Canadians $7 billion per year (Shapcott, 2006).
There are several solutions to reduce emergency room utilization and provide a safe discharge environment for those experiencing homelessness presented in the literature that reduce healthcare costs and congestion. Levesque et. al. (2013) proposes a patient centered framework for access to healthcare as depicted in Figure 3. In this framework, access to healthcare is an interaction between the person, their characteristics, and their social and physical environments and the features of the healthcare system, the approachability of the healthcare providers and the location of the services it provides. Levesque et. al. recognize that not only does the healthcare system need to provide the service, but the person must also possess the health care literacy to understand the need to seek healthcare and have the means to get to the service. As I think about improving the health of homeless individuals by improving access to healthcare, this framework helps point out some of the considerations required.
Figure 3
Note: This figure illustrates the ‘Patient Centered Access to Health Care’ which is a conceptual framework described by Levesque et al (2013).
Park et. al. (2017) held focus groups with recently discharged patients experiencing homelessness and found that short term stays in a respite facility to allow for recovery, reduced hospital stays and lowered hospital readmission rates. Park et. al. found that these facilities were most successful when carefully planned with input from individuals who have experienced homelessness, and that offer housing services and careful discharge planning by non-judgement staff. Another suggestion was to employ an ombudsperson who had previously experienced homelessness as a patient advocate (Park et. al., 2017).
Ali (2017) describes one way to make healthcare more accessible to homeless Canadians on her post on the Homeless Hub website. She highlights street medicine teams that take healthcare directly to the homeless to reduce emergency room visits as showcased in Video 1.
Video 1
Note: Street Medicine Teams Patrol for Homeless Health (AJ+, 2016) and illustrates taking healthcare to the individual instead of having the individual seek healthcare independently.
The Homeless Hub (n.d.) outlines Housing First as a philosophy where housing is provided without the conditions of sobriety and then wraps the support services for employment, education, mental and physical health, and substance abuse around the individual. This philosophy views housing as a basic human right that provides the foundation for a person to move forward (Homeless Hub, n.d.). The supports are offered should the individual choose to use them and are not a condition of the housing (Homeless Hub, n.d.).
As a healthcare system and as a province, it is clear we have work to do in preventing and ending homelessness and improving healthcare access for those that are homeless. Frankish et. al. (2005) highlight that interventions that provide a combination of housing and healthcare show the most success along with a good dose of healthy public policy at all levels of government. In thinking about my current role, I wonder about what part I have played in the past when working with homeless individuals and if my interventions have missed the mark. Going forward, I have a much deeper understanding of the role I must play in removing stigma and barriers for those that are homeless as they move through the acute care hospital and continue their recovery in the community.
References:
Adhikari, S. (2017, May 17). Social Determinants of Health (SDH). Public Health Notes. Retrieved April 1, 2021, from https://www.publichealthnotes.com/social-determinants-health-sdh/
AJ+. (2016, Mar 16). Street Medicine Teams Patrol for Homeless Health [Video]. YouTube. https://www.youtube.com/watch?v=m0LC_GIn9hE
Ali, N. (2017, April 18). Hospital Emergency Care and Homelessness. Homeless Hub. https://www.homelesshub.ca/blog/hospital-emergency-care-homelessness
Canadian Institute for Health Information. (n.d.). Acute care. Retrieved March 30, 2021, from https://www.cihi.ca/en/acute-care
Canadian Institute for Health Information. (2009). “Alternate Level of Care in Canada.” Analysis in Brief. Retrieved April 2, 2021. https://secure.cihi.ca/free_products/ALC_AIB_FINAL.pdf
Feigal, J., Park, B., Bramante, C., Nordgaard, C., Menk, J., & Song, J. (2014). Homelessness and discharge delays from an urban safety net hospital. Public Health, 128(11), 1033–1035. https://doi.org/10.1016/j.puhe.2014.06.001
Frankish, C. J., Hwang, S. W., & Quantz, D. (2005). Homelessness and Health in Canada Research Lessons and Priorities. Canadian Journal of Public Health, 96(2), S23-S29.
Fraser Institute News Release: Canada one of the highest spenders on health-care among universal access countries; ranks near bottom on number of doctors, hospital beds and wait times. (2020, November 10). Marketwired, NA. https://link.gale.com/apps/doc/A641114289/AONE?u=atha49011&sid=AONE&xid=80c561da
Homeless Hub (n.d.). Housing First. Homeless Hub. https://homelesshub.ca/solutions/housing-accommodation-and-supports/housing-first
Jaworsky, D., Gadermann, A., Duhoux, A., Naismith, T. E., Norena, M., To, M. J., Hwang, S. W., & Palepu, A. (n.d.). Residential Stability Reduces Unmet Health Care Needs and Emergency Department Utilization among a Cohort of Homeless and Vulnerably Housed Persons in Canada. Journal of Urban Health, 93(4). https://doi.org/10.1007/s11524-016-0065-6
Khandor, E., Mason, K., Chambers, C., Rossiter, K., Cowan, L., & Hwang, S. W. (2011). Access to primary health care among homeless adults in Toronto, Canada: Results from the street health survey. Open Medicine, 5(2), 94–103. /pmc/articles/PMC3148004/
Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12(1), 18. https://doi.org/10.1186/1475-9276-12-18
Menec, V.H., Bruce, S., & MacWilliam, L. (2005). Exploring Reasons for Bed Pressures in Winnipeg Acute Care Hospitals. Canadian Journal on Aging, 24, 121-131. http://doi.org/10.1353/cja.2005.0051
Park, B., Beckman, E., Glatz, C., Pisansky, A. & Song, J. (2017). A place to heal: a qualitative focus group study of respite care preferences among individuals experiencing homelessness. Journal of Social Distress & the Homeless , 26(2), 104-115.
Roberge, D., Pineault, R., Larouche, D., & Poirier, L. R. (2010). The continuing saga of emergency room overcrowding: Are we aiming at the right target? In Healthcare Policy (Vol. 5, Issue 3, pp. 27–39). Longwoods Publishing Corp. https://doi.org/10.12927/hcpol.2013.21637
Smith, R. (n.d.). The end of disease and the beginning of health. The BMJ. Retrieved April 5, 2021, from https://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/
Skosireva, A., O’Campo, P., Zerger, S., Chambers, C., Gapka, S., & Stergiopoulos, V. (2014). Different faces of discrimination: Perceived discrimination among homeless adults with mental illness in healthcare settings. BMC Health Services Research, 14(1), 376. https://doi.org/10.1186/1472-6963-14-376
The Homelessness Services Association of BC, Urban Matters, and BC Non-Profit Housing Association (2018). 2018 Report on Homeless Counts in B.C. Prepared for BC Housing. Burnaby, BC: Metro Vancouver.
The Lancet. (2009). What is health? The ability to adapt. In The Lancet (Vol. 373, Issue 9666, p. 781). https://doi.org/10.1016/S0140-6736(09)60456-6
World Health Organization. (n.d.) Social determinants of health. Retrieved April 1, 2021, from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
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