The past decade in Canada has seen a material escalation in visible homelessness. With a highly financialized housing market driving housing unaffordability and escalating inflation putting pressure on mortgages, rents and food, the crisis of homelessness has continued to worsen.
This has resulted in considerable social, emotional and health-related consequences for a growing population experiencing homelessness while also placing enormous economic and infrastructural pressures on the social institutions that provide care to this population.
This strain is felt acutely in Canada’s emergency departments (EDs).
People experiencing homelessness have a two to five times higher morbidity and mortality from all diseases compared to the general population and often have no choice but to use EDs for their health care. Emergency health-care workers must in turn contend with responding to the complex comorbidities that accompany a life of living rough and have little recourse to affect the underlying pathologies that engender a revolving-door relationship that many unhoused patients have with EDs across Canada.
Fundamentally, being unhoused is the primary medical concern facing this population, but chronically overcrowded EDs rooted in disease-oriented and episodic models of acute care are not well oriented to respond to this reality. The result is countless individuals cyclically discharged back into homelessness, with poorer access to care for all Canadians.
While the situation appears bleak, it’s important to appreciate that EDs, as the nexus point of individual and social maladies, often are the only resource in the health-care system for unhoused patients. Because of this, EDs hold profound potential as spaces that could reimagine the adequate provision of care for people experiencing homelessness.
By addressing not only the myriad pathologies generated through a life of displacement, forced mobility and environmental exposure, but also a lack of housing as the foundational social determinant of health that underlies those pathologies, it is not only possible but morally necessary for EDs to be one of the strongest social services for responding to this crisis.
What then would such a system look like? To answer that question, it’s important to look at the growing role of social prescribing within health care.
In recent decades, social prescriptions have emerged as a novel tool to address the biomedical basis of patients’ presentations, situated within their specific social milieu. Unlike pharmaceutical and lifestyle interventions, social prescriptions (ranging from prescriptions for dance therapy, outdoor activity, art classes, volunteering, access to income support and, importantly, housing interventions) are ways that physicians can recognize the variegated impact of social determinants of health across patients and work to intervene at the level most appropriate for a given patient’s medical needs.
While social prescriptions have largely been the purview of primary care, there is growing recognition of their utility within EDs. Looking specifically at housing as a social prescription, research has consistently demonstrated that EDs are key sites where this intervention can be initiated and where it may have its greatest impact.
Providing permanent housing without preconditions for sobriety or “appropriate” mental and physical health (known as “Housing First”) is not only something that can and has been realistically implemented for unhoused patients in EDs, it also has been shown to reduce ED visits and hospitalizations, help patients maintain housing long-term and produce health benefits.
Coupled with effective case management via social workers, Housing First interventions reduce total hospital usage by those who are the most intensive users of emergency services. A randomized control trial investigating the provision of case management and supportive housing for individuals discharged from hospital in Chicago demonstrated a 29 per cent reduction in hospital days and 24 per cent reduction in ED visits over an 18-month follow-up.
The effectiveness of providing housing for unhoused patients is so clearly recognized by the medical community that permanent supportive housing is strongly recommended within the clinical guidelines for homeless and vulnerably housed people.
Housing prescriptions in practice
But what would prescribing housing in EDs look like in practice?
An example of one such program is the Bridge Healing Transitional Accommodation program run by Louis Hugo Francescutti, an emergency and preventive medicine physician in Edmonton who contributed to this article. The program, supported by Alberta Health Services, provides 36 transitional beds for people experiencing homelessness upon discharge from the ED. Patients are allowed various lengths of stay while they are set up with more permanent housing options, all while being provided with community health services like addiction and mental health home care.
The reality is that social prescriptions for housing mean nothing if the housing is unavailable.
In the U.S., physicians in Portland, Ore., have also been successfully prescribing housing through a non-profit agency, Central City Concern, that operates housing while equipped with a team of family medicine physicians, health-care support workers and wraparound social services. In Toronto, Andrew Boozary partnered with city government and non-profits to build a new, four-storey building on University Health Network hospital land to provide housing for unhoused patients.
The reality is that social prescriptions for housing mean nothing if the housing is unavailable. Beyond physicians’ good intentions, housing prescriptions require broad coordination between health systems, all levels of government, non-profits, community organizations, and patients themselves, but those networks are not always readily in place.
This is precisely why, in 1848, Rudolph Virchow declared social problems to be “largely within the jurisdiction” of physicians; in the absence of coordinated leadership to address the underlying pathologies of poverty and social disadvantage that engender homelessness, physicians must be willing to advocate to ensure the treatments they know their patients require are actively available. In a publicly funded health-care system, it would be unacceptable for insulin to be unavailable for a patient with diabetes – we must treat housing for unhoused patients with the same moral urgency.
Housing prescriptions as multidisciplinary care
Housing prescriptions also produce positive ripple effects on how health care is imagined and delivered. While prescribing is largely a physician’s role, housing prescriptions are unique in that their provision requires longitudinal, multidisciplinary care teams by definition.
In busy EDs, this is especially valuable, as housing instability and homelessness are not always immediately recognizable by physicians alone. Moreover, even the most equity-minded ED physicians may not be the best lead points of contact for unhoused patients, whether because of time constraints placed on them due to chronic levels of overcrowding or the reality that EDs and affiliated staff frequently are regarded as sources of stigma and discrimination by unhoused patients.
Programs like the Connect 2 Care initiative in Calgary have responded by using “health navigators” – non-clinicians who have experience working with vulnerable populations – to help unhoused patients connect with the housing and social services. In doing so, Connect 2 Care is a clear example of how housing prescriptions can be executed without burdening already overwhelmed ED staff.
Having non-clinicians lead these interventions also is helpful in that it provides patients with higher levels of trust, autonomy and social capital, giving them the confidence, connections and knowledge necessary to manage their health and well-being and reduce their overall reliance on health care.
And, as with any prescription, the housing provided needs to be appropriately tailored to match a given patient’s medical needs, whether that is independent housing, housing with wraparound social services, geographically appropriate housing, housing suited to cultural and gender-based needs or housing that accommodates the diverse range of disabilities that unhoused patients disproportionately live with. Housing that does not accommodate the specific social circumstance of the patient is akin to a pharmaceutical intervention that a patient cannot afford.
The social cost
It is easy to point out the central limitation of housing prescriptions — in the current climate of housing unaffordability, escalating income inequality and dismantling of publicly supported housing under neoliberal austerity governments, there is a fundamental mismatch between the housing required to house unhoused patients and the housing currently made available to them.
However, this mismatch is one generated by a lack of political imagination and is largely contradicted by the gestures towards economic pragmatism that routinely hold such public spending projects back.
As Boozary has demonstrated, it can cost more than $30,000 per month to keep a patient in a hospital ward, $7,000 to be in a sheltering system or $2,500-$2,800 for supportive housing. These savings are compounded by the savings generated through reduced ED visits for unhoused patients, better health-care outcomes for those patients and the social benefit of reduced ED crowding for all Canadians. In British Columbia alone, it has been estimated that providing adequate housing and support services for its population would result in savings of $211 million. And the savings would not be limited to health-care spending – housing first has also been shown to provide savings to the justice system.
In a context in which homelessness costs Canadian society upwards of $7 billion annually and generates profound morbidity and mortality, it is both morally unacceptable and economically irresponsible to continue on the current path. The fact that Canada’s EDs are on the frontlines of the crisis of homelessness is an indictment of the way our country has deprioritized the wellbeing and social safety of those who are unhoused.
However, within this reality, we also find a critical opportunity for health care to reimagine the adequate provision of care for this population, starting with the foundational, fundamental human right to housing.