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Towards a homegrown approach to addressing health for Canada’s homeless


Sayid is a 65 year old South Asian man from Toronto. He has schizophrenia, but with the proper medications and supports, his illness is well controlled, allowing him to work full-time in a manufacturing job. For years, like many of Toronto’s working poor, he lived paycheque to paycheque. When his company underwent downsizing, Sayid lost his job and then his home. Shunned by his cultural community due to stigma and without a network of support to rely on, he turned to Toronto’s shelter system for a safe place to stay. After suffering an assault and robbery one night at the hands of others living at the shelter, Sayid was left without any of his belongings, including his medications. Fearing for his safety, Sayid fled from Toronto’s streets to seek shelter in a tent in the Don River Valley, where he has lived on and off for the past ten years.

We met Sayid after he was hospitalized due to an exacerbation of a pre-existing heart condition and foot pain related to long-standing diabetes and chronic exposure to dampness. His admission, the fourth in a six-month period, was largely related to his inability to take his medications as prescribed, lack of an appropriate diet, and limited access to a primary healthcare provider. Generally, he stayed clear of the healthcare system due to discomfort and fear after experiencing discrimination in numerous Emergency Departments and clinics. Furthermore, when he did seek medical attention, his healthcare providers would often suggest unrealistic treatment plans that did not take his unique set of social and living conditions into account.

In the United States, the National Healthcare for the Homeless Council (NHCHC) has established Clinical Practice Guidelines for care of the homeless to address the fact that chronic homelessness can significantly limit a patient’s ability to adhere to a plan of care. Had Sayid’s healthcare providers had access to evidence-based Canadian guidelines to assist them in the care of homeless patients within a local context, we believe that Sayid’s difficult experiences could have been prevented.

Sayid’s story is not uncommon. In fact, it is one of over 2000 that researchers have heard from homeless individuals across Canada who are enrolled in the At Home/Chez Soi Demonstration Project. This five-site (Toronto, Winnipeg, Moncton, Montreal and Vancouver), five-year, longitudinal study funded by the Mental Health Commission of Canada, is currently investigating ‘Housing First’ as an effective intervention for chronic homelessness. Through the provision of homes to 1000 study participants, we are seeing the way that safe and guaranteed housing is a more efficient and effective way to improve the lives of the homeless. In the Toronto arm of the study, we are conducting an analysis of the medical care that our study participants receive, in order to better understand the quality of healthcare provided to the homeless population.

Similar to Sayid, many homeless Canadians experience perpetual worsening of their physical and mental health for reasons that are, for the most part, preventable. Those who stay on the streets often lack access to clean water to take their medication or a safe place to store them. Further, most homeless individuals are unable to access nutritious meals to keep them healthy. When the homeless do receive care, the more frequent users of healthcare institutions report experiencing stigma and discrimination from healthcare providers and authorities. For others, accessing healthcare can be challenging for simple reasons, like having their health card stolen. Finally, up to 67% of the homeless have at some point been diagnosed with a mental illness, which itself is an obstacle to utilizing our universal healthcare system.

The NHCHC guidelines used in the United States are accessed by healthcare providers in a variety of settings and have become the nation’s go-to resource for homeless health provision and education. “The development of evidence-based, homeless-specific Adapted Clinical Guidelines has helped us to firmly establish that people experiencing homelessness have distinctive health care needs that require tailored interventions,” says NHCHC Executive Director, John Lozier. We feel that the homeless in Canada and the United States, and the healthcare systems in which they seek care, are sufficiently different in nature, such that a distinctly Canadian set of evidence-based guidelines will serve to improve the physical and mental health outcomes of our most vulnerable and marginalized. Differences in demographics (e.g. Aboriginal and immigrant populations), causes of mortality and morbidity and access to medical care, underscore a few of the reasons for the development of Canadian guidelines for the homeless.

Clinical Practice Guidelines specific for Canada’s homeless could lead to increased consistency, application and dissemination of best practices in care, thereby empowering healthcare providers to address the lives of these patients holistically, within a locally relevant context. “Increasingly, the social determinants of health are recognized as central to health status, but they are too often understood as phenomena well beyond the reach of healthcare practitioners,” adds John Lozier. Canadian-specific guidelines have the potential to lead to more effective implementation of preventative health measures, early identification of medical issues more commonly seen in homeless patients and more sensitive and less stigmatizing care by healthcare providers. For example, Canadian guidelines could assist healthcare providers in the management of less commonly seen presentations, such as the effects of Canada’s extreme weather patterns (e.g. heat, frostnip, frostbite, trench foot) on a population that is more exposed to the elements. Further, these guidelines could help practitioners by listing locally-relevant opportunities and resources that can potentially increase income and thereby reduce the effects of poverty on health (e.g. navigating provincial disability paperwork, special diet forms, local assistance programs for the homeless). These benefits are especially important given chronic homelessness’ heavy cost to Canadian society and the growing body of literature that supports the stigmatization of homeless populations in healthcare institutions.

As for Sayid, housing, supportive case management and attentive medical care provided through the study have contributed to improved physical and mental health, which has led to increased confidence and hope for the future. With approximately 300,000 homeless Canadians and 10,000 living on the streets without shelter on any given night, we hope that Sayid’s experience can become the norm, through ‘Housing First’.

Excellent Clinical Practice Guidelines have already been established for other vulnerable populations in Canada, such as for the care of immigrants and refugees. Initiatives like the At Home/Chez Soi Demonstration Project contribute to a larger body of knowledge aimed at addressing the challenges and obstacles that Canada’s homeless face on a day-to-day basis. We continue to seek solutions to end chronic homelessness. In the meantime, the development of evidence-based guidelines that address the unique needs of homeless people in Canada is a necessary step forward to improving the health of this marginalized population.

We would like to acknowledge Drs. Stephen W. Hwang and Abbas Ghavam-Rassoul for their support and guidance in the creation of this piece.

Naheed Dosani is a Family Medicine Resident Physician with the Department of Family and Community Medicine at the University of Toronto and is training at St. Michael’s Hospital. Follow Naheed on Twitter @NaheedD. Adam Whisler is a Research Coordinator for the At Home/Chez Soi Demonstration Project at the Centre for Research on Inner City Health at St. Michael’s Hospital. Follow Adam on Twitter @WhislerA.

This article was originally posted on the National Film Board’s ‘Here at Home: In Search of the Real Cost of Homelessness’ blog.

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  1. Emily Nicholas

    Dear Naheed et al,

    Thank you for this eye-opening, thoughtful and informative piece.
    It’s amazing how a patient narrative can so clearly illustrate the inadequacy of our current system. Statistics about joblessness, homelessness and poverty run abound, especially during times of economic struggles. Watching these numbers rise and fall can mean losing the grip on the reality of what they truly represent. People. Each one has a story and a context. We all live on a continuum, none of us are immune to a particular fate. Through empathy for those who have been dealt a different set of cards,we can move past labels and categories which separate us. More research to establish best-practices and clinic guidelines is absolutely needed. It must result from evidence, arrived at via careful methods and strong statistical analysis. We also need to be open to a discussion which engages all stakeholders (for lack of a better word). Input from those with experience, like Sayid, will be essential in the creation of effective and sustainable policies.

    Thanks again for your excellent blog!

    Sincerely,

    Emily Nicholas
    Board Member Patients’ Association of Canada

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