When Jane was asked if she was excited to leave the psychiatric hospital, her first reaction was: “Where do I go?” Jane, still in her teens, had been sexually abused and was battling addiction and homeless. She wasn’t aware of an alternative discharge option besides sleeping on that same stoop on a busy street.
Homelessness at hospital discharge for those with mental illness/addictions is an issue for more than just Jane. Across Ontario, more than 1 in 50 adult patients from psychiatric hospitalizations are homeless at discharge.
Vicky Stergiopoulos, who recently stepped down as physician-in-chief of the Centre for Addiction and Mental Health (CAMH), recalls that when she worked at St. Michael’s Hospital in downtown Toronto, one in five of her patients was homeless.
“It was very hard to feel good about the care you provide … and (that) the care you provided can have a positive impact. But how can you when you see them being discharged to go back to the pavement on the street, or in a shelter setting with no support?” asks Stergiopoulos. “And the moral distress associated with that, it’s very uncomfortable.”
Psychiatrist Sarah Levitt has seen that distress in her inpatient practice. “There’s a lot of pressure on the staff, in terms of bed pressures, and making sure that when folks don’t absolutely have to be in hospital, they are discharged,” she says. “And at the same time, from a compassionate perspective, it feels so awful to be discharging people with nowhere to go.”
Homelessness at discharge in psychiatric settings comes with significant cost to our health-care system and, more importantly, to those with lived experience. Homelessness at psychiatric discharge nearly doubles mental-health related emergency department visits and increases readmission rates by 43 per cent within 30 days of discharge compared to those with housing.
“If people think that their best housing option is to stay in hospital, then there’s something really wrong with our system.”
“If people think that their best housing option is to stay in hospital, then there’s something really wrong with our system,” Levitt says.
And it doesn’t just end with one readmission. Says Melonie Hopkins, a social worker who manages Alternative Level of Care (ALC) at a mental health hospital: “(For) those individuals who are homeless upon admission, and they return to homelessness, you can get this revolving door.”
Sean Kidd, psychologist and senior scientist at CAMH, says health-care workers have little choice but to discharge patients.
“We are really underfunded. We cannot meet the demands and needs of the people we’re trying to serve,” says Kidd. “So, it’s not like any hospital or any provider of any kind is thinking it’s a good idea to discharge somebody into no fixed address or to a shelter. It’s just a matter there’s no choice …”
Jesse Jenkinson, postdoctoral fellow at the MAP Centre for Urban Health Solutions, points to the shortage of shelter beds as a major barrier.
“There literally aren’t any spaces for people to go. A shelter space is already a suboptimal discharge destination for someone leaving the hospital. But it’s the only option that exists for most people,” says Jenkinson. “And now… we don’t have that option either. So, it’s very bad.” At the time of writing, the shelter bed occupancy in Toronto ranged from 94.5 to 100 per cent.
Currently, there is no provincial strategy for discharging people experiencing homelessness from hospital settings. Though there are best practices outlined by the Ontario Hospital Association to confirm with provincial legislation and funding, Stergiopoulos “doubt(s) there is close attention across the province on what happens at discharge.”
Says Jenkinson about those best practices: “It doesn’t include the word homeless in any of the documents … I think that gets very tricky.”
Hopkins’ ALC clients have a diverse set of care needs in addition to mental illness. Her clients stay in hospital for “even years just waiting for housing.” And that, says Hopkins, “reduces our capacity to serve individuals who are more appropriate (for treatment) and more acutely ill at that time.” While Hopkins would not say how many people are on the ALC waitlist, she said “it’s very, very long.”
“Giving a person a key is just one part… You also need other supports in place.”
Levitt, Hopkins and Kidd emphasize the urgent need for more affordable and supportive housing. But, “it’s not enough just to give a person a key,” notes Kidd. “Giving a person a key is just one part because if you want that person to move forward in meaningful areas of life and stay out of hospital. You need other supports in place.”
There are initiatives like Housing First, in which housing is granted before treatment along with supports like assertive community treatment or intensive case management. Though the program showed promise during pan-Canadian trials, Kidd says “it has really lost momentum in Canada, and it’s become quite watered down.”
Under the previous federal homelessness program, there was mandatory investment in Housing First but it was removed in 2019. Tim Aubry, professor of psychology and co-lead of the Moncton site in the trials, says “there was some growth (with Housing First), but it has kind of stalled since that time.”
Another initiative that has shown promise is CATCH (Coordinated Access To Care from Hospital), which helps people who experience homelessness, with or without mental health or addiction problems, connect to services in their community. CATCH Translational Case Managers work in three of Toronto’s hospitals and with referred clients in the community.
The lack of funding has been “the main barrier” to upscaling CATCH, says Stergiopolous, leaving us at risk of falling behind other jurisdictions. “Critical Time Intervention Models, like CATCH, are expanding internationally,” she says.
The rapid transformation of hotels into shelters during the height of the pandemic, while a temporary solution, makes Jenkinson optimistic.
“We’re at a point right now where there’s a window of opportunity to make that shift,” she says. “It’s going to require some evidence and advocacy on everyone’s part to push for some of these changes that we know are really important and could improve people’s lives.”
Kidd mentions that changing perceptions means seeing through the stigma of homelessness and mental illness. “Ultimately, what’s going to change perceptions is (to) see people’s humanity.”