People experiencing homelessness have worse health outcomes than the general population and limited access to primary/preventative healthcare. This leads to high hospital readmission rates. Effective discharge planning can improve recovery rates and reduce hospital costs. However, most hospital discharge policies and best practice guidelines are not tailored to patients with no fixed address, contributing to inappropriate discharges and health inequities for people experiencing homelessness. We discuss the lack of discharge policies, identifiable processes or plans specifically tailored to this population as a healthcare and policy gap, and we identify key areas for better understanding and addressing this issue.

Introduction

Every hospital has patients who frequent their emergency departments. They are often individuals in precarious situations who are discharged after receiving care, only to return shortly thereafter for the same or related health issues. Many of these patients are readmitted because they are unable to complete follow-up care, experiencing multiple social challenges and limited supports outside the hospital. Hospitals are particularly challenged in this regard by people experiencing homelessness. 

Discharge planning aims to effectively transition a patient's care from the hospital to the community, addressing the interdisciplinary care needs for a patient's recovery. Individuals experiencing homelessness are most commonly discharged to emergency shelters or the streets. These destinations lack resources to support critical follow-up care and can exacerbate existing mental and physical health issues. With few alternative discharge destinations available, such as affordable and supportive housing, these types of discharges exemplify a broader systemic failure for people experiencing homelessness.

The goal of this commentary is twofold. First, to bring attention to a glaring healthcare and policy gap – a lack of discharge policies or identifiable processes specifically tailored to this population. Second, to propose possible pathways toward redressing this gap. The importance of hospital discharge planning should not be underestimated. Effective discharge planning is an important part of a systems approach transitioning people out of homelessness (Backer et al. 2007). While addressing homelessness requires broad social and economic changes fuelled by the political will to ensure the right to housing, this commentary focuses on individuals experiencing homelessness for whom hospital discharge policies are ill-adapted. We review the link between homelessness and health. We then explain issues in the hospital discharge of people experiencing homelessness. Finally, we provide suggestions for better understanding and addressing this issue. We draw on the Ontario provincial context to inform our discussion, but the issues identified here are common across many geographic contexts, and suggestions for moving forward can be drawn on to inform action more broadly.

The Link between Homelessness and Health

The current state of homelessness in Canada has been described as a national disaster (Shelter and Housing Justice Network n.d.). Homelessness has progressively worsened since the 1990s as a result of reduced investments from the federal government in affordable housing, economic shifts impacting employment opportunities and decreased spending on health and social services (Gaetz et al. 2016). Increasing costs of living, a shortage of affordable housing and decreased social and financial supports place people with untreated or unsupported mental health and substance use issues at a higher risk of entering homelessness. The development of a National Housing Strategy (https://www.placetocallhome.ca/) and Housing First approaches (Stergiopoulos et al. 2019) are both promising long-term solutions; in the meantime, tens of thousands of individuals remain in situations of homelessness in Canada (Government of Canada 2019).

The negative physical health, mental health and psychosocial impacts of homelessness are well documented. The contexts in which homeless individuals live increase exposure to rough climates, psychological strain and communicable diseases, leading to worse health outcomes (Public Health Ontario 2019) and higher rates of mortality at younger ages than the general population (Morrison 2009). Homeless populations also suffer disproportionately from poor mental health, often comorbid with substance use (Medlow et al. 2014).

Housing status affects access to preventive or primary healthcare, and therefore, people experiencing homelessness use the acute healthcare system at higher rates than the general population (Hwang et al. 2013). Healthcare needs for people experiencing homelessness may be more advanced and complex than for their housed, low-income peers, resulting in longer average in-patient stays (Hwang et al. 2011). Longer in-patient stays may also be associated with difficult discharges (e.g., difficulty finding a discharge destination to meet the patient's complex needs). These admissions have financial impacts for the healthcare system. Longer hospital stays for homeless patients are associated with increased costs for treating these patients (in Toronto, $961 more per admission for homeless than housed patients, or $2,559 more when adjusting for age, gender and resource intensity; Hwang et al. 2011). People experiencing homelessness are less able to access care at early stages of illness, resulting in more severe and complex symptoms by the time they present at hospitals, as well as correspondingly higher rates of hospital admission.

It is against this backdrop that homeless patients experience greater disadvantage at discharge from acute care hospitals compared to their domiciled counterparts. Insufficient access to follow-up care is often associated with worsening health outcomes, so having an effective discharge plan in place is critical. Without an effective plan, or the resources to adhere to it, people experiencing homelessness are more challenged in recovery.

Hospital Discharge for Housed and Homeless Individuals

The point at which a patient is discharged from a hospital is a key transition in their care pathway, providing opportunities to address a patient's health and social needs (Fader and Phillips 2012). Discharge plans may involve improving the physical accessibility of a patient's existing housing or plans for coordinating care around the patient in their community. It may also involve changes to where patients live, such as applying to move into long-term care. Best practice guidelines (e.g., "Managing Transitions" by the Ontario Hospital Association) assume a fixed discharge destination. There is little formal knowledge of best practice for discharging patients with no fixed address from non-psychiatric hospitals, including what types of planning best support successful follow-up care, and how to execute such a plan in light of resource and social service constraints. Currently, there is no provincial strategy for discharging people experiencing homelessness from acute care health settings, and we were challenged to find publicly available hospital policies or guidelines that are tailored to people experiencing homelessness.

Hospital discharge for people experiencing homelessness remains a complex and challenging process, particularly in the face of limited housing or shelter resource availability; yet, there is a lack of research in this area. The literature on discharge planning focuses on those who have a stable home and on the discharge of patients (both homeless and housed) from tertiary mental healthcare (Gonçalves-Bradley et al. 2016; Xiao et al. 2019). Effective discharge models have been developed for people experiencing homelessness when leaving acute and tertiary psychiatric hospitals (e.g., Forchuk et al. 2013); however, their appropriateness for non-psychiatric hospital contexts is unclear. We identified limited research within the Canadian context that examines the hospital discharge of individuals from non-psychiatric hospital wards who are currently homeless or precariously housed. Furthermore, although a 2015 provincial report by the expert panel on homelessness identifies transitions from provincially funded institutions as effective points of intervention, we failed to find provincial policy documents or statements that identify the connection between discharge planning and homelessness (Ontario Provincial Government 2015).

Although people experiencing homelessness are frequently discharged to emergency shelters, this discharge pathway does not provide a fixed or long-term solution and puts a strain on emergency housing facilities. Most emergency shelters are not equipped to provide post-discharge healthcare for individuals (Tansley and Gray 2009), and community care is not meeting the needs of the population (Kiran et al. 2020). Overloading the shelter system with patients discharged from hospitals who require health resources not readily available within shelters is an ineffective way of supporting people experiencing homelessness. Although interim healthcare facilities, such as medical respite centres, provide a short-term post-discharge option, these are few and far between, with limited bed space and restrictive and exclusionary rules on patient/client behaviour, and often require that the patients have a fixed address to go to after leaving respite care.

What Is Needed?

Addressing this issue will require the coordination of services between federal, provincial and municipal levels of the government and across multiple sectors. Hospital discharge planning is a key point of service that can be leveraged to help address the needs of people experiencing homelessness, and that doing so is an important part of a larger approach to addressing health inequities for this population. To explore these issues, our team is working on a qualitative research study that examines the experiences of discharge planners working with people experiencing homelessness in Toronto, Canada. We have identified the following key areas that require further attention:

1. Evaluative and exploratory research: There is a limited public-facing understanding of the actual process of discharging patients with no fixed address. To properly identify the scope of the problem and develop appropriate responses, hospitals that serve people experiencing homelessness should conduct needs assessments to clarify the decision-making process in hospitals surrounding discharge for this patient population, as well as the nature of care available and accessible post-discharge. Collaboration and information sharing between hospitals – that is, in a network setting – and other agencies (e.g., shelters) could support this goal.
2. A policy priority: Developing targeted, contextually flexible interventions and specific policies and practices around discharge planning that meet the needs of people experiencing homelessness is urgently needed. Yet, there remains limited provincial government investment on hospital discharge for this patient population, particularly from non-psychiatric hospitals. The challenge lies in the intergovernmental and the intersectoral nature of this issue. Housing is funded at the federal level, and emergency shelters are administered and managed by municipalities. Healthcare is overseen by the provincial government. Adequately addressing the issue requires an unprecedented collaboration from all levels of governments to work together across portfolios concerning both housing and health. Inadequate responses to the COVID-19 pandemic for people experiencing homelessness provide a clear example where poor coordination and collaboration have delayed the implementation of appropriate public health measures (e.g., social distancing, testing) in shelters and moving homeless individuals into housing.
3. Data generation: Problematically, there is a dearth of post-discharge outcome data for people experiencing homelessness. Without this evidence, it remains challenging to build a compelling case to policy makers for addressing this issue. There are multiple reasons for this lack of data. First, the transient nature of this population makes following and tracking patients with no fixed address challenging. Second, hospital information systems do not consistently identify patients with no fixed address in a way that can be tracked within administrative data sets (Greysen et al. 2013). Moreover, shelters and drop-in centres often intentionally gather limited identifying information to operate as low-barrier facilities. Innovative ways of collecting data that take these contexts into account are needed. Several agencies (e.g., ICES and the Canadian Institute for Health Information) are already collecting information on patient health outcomes. These agencies could further develop their work to specifically explore health outcomes for individuals experiencing homelessness.
4. System improvements: Improvements need to be made within and between the healthcare and social service sectors. Programs are often short-term, one-off interventions that show short-term improvements for people experiencing homelessness but are not necessarily permanently integrated into daily practice. A combination of short-term and long-term improvements is needed to sustainably address the needs of this population. Specific system solutions should be developed in partnership with people with lived experience of homelessness; representatives from both health and housing sectors across municipal, provincial and federal levels of government; and networks focused on homelessness (e.g., The Canadian Alliance to End Homelessness). Such an approach could potentially be supported within the National Housing Strategy.

Conclusion

Hospital discharge is geared toward sending someone to a fixed address, yet most people experiencing homelessness do not fit into this discharge pathway. The Ontario Hospital Association identifies a number of discharge or transfer destinations, including emergency shelters (Byrick 2016). Including shelters as a legitimate discharge destination reflects the current context of housing and care options available for people experiencing homelessness; this discharge pathway also exacerbates health inequities through barriers to follow-up care and can create complications when the clinical recommendations made do not align with available resources at the discharge destination. This is an incredibly complex and multifaceted issue that requires further research and policy consideration. Ideally, affordable, secure and supportive housing would be available for patients upon hospital discharge. Until the right to housing is actualized, creating tailored discharge policies and processes will provide an opportunity to intervene in the current discharge experiences for people experiencing homelessness. Greater coordination, communication and collaboration are required to rectify this policy gap and address health inequities for homeless populations.

Conflict of Interest

The views expressed in this article are those of the authors and do not reflect the position of the University of Toronto, Sunnybrook Hospital, the Ministry of the Attorney General, McGill University Health Centre, or any other agency.

Planification des sorties d'hôpital pour les personnes en situation d'itinérance qui ont reçu des soins de courte durée : un enjeu négligé

Résumé

Les résultats cliniques des personnes en situation d'itinérance sont moins bons que ceux du reste de la population et leur accès aux soins de santé primaires ou préventifs demeure limité. Cela donne lieu à de forts taux de réadmission à l'hôpital. Une planification efficace des sorties pourrait améliorer le taux de rétablissement et réduire les coûts hospitaliers. Cependant, la plupart des politiques de sortie ainsi que les pratiques exemplaires ne sont pas conçues pour les patients sans domicile fixe, ce qui se traduit par des sorties inappropriées et des inégalités en matière de santé pour ces personnes. Nous discutons du manque de politiques de sortie, de processus identifiables ou de plans spécialement conçus pour ce groupe, ce qui constitue une lacune en matière de services de santé et de politiques. Nous identifions des secteurs clés pour mieux comprendre et traiter cet enjeu.

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