Introduction

The recent winter months were particularly brutal for the healthcare system and its patients as we grappled with an onslaught of infectious diseases, healthcare backlogs and critical shortages of health human resources. We subsequently watched as Canada's federal and provincial leaders sought agreement on additional investments for several of our most precarious sectors, including long-term care, primary care and mental healthcare. Spring 2023 offers some optimism in that we will have new resources to make much-needed improvements to our depleted health sectors and services. While we can anticipate ongoing tensions as to how these investments will be used and how political leaders are held accountable, our healthcare leaders are gearing up to increase capacity and shore up our systems.

As we look to the future, our Healthcare Quarterly (HQ) editorial team is committed to promoting the importance of health equity in systems recovery and renewal and to drawing attention to populations that may not always be front and centre. In this edition of HQ, our focus on supporting underserved communities includes articles about improving access to care for individuals dealing with homelessness or who are unstably housed and enhancing the health of individuals with severe mental illness. From there we shift to other topics, including the omnipresent COVID-19 pandemic and an interview with Heather Patterson on her recently published photobook about the COVID-19 pandemic (Wojtak and Stuart 2023). We also feature articles that touch on healthcare redesign along with our regular featured columns from ICES, the Canadian Institute for Health Information (CIHI) and our colleague Neil Seeman.

Supporting Underserved Communities

In our first article, Ecker et al. (2023) describe the Beyond Housing program that offered a combination of intensive case management and access to community-based mental health and social supports for residents living in temporary shelter hotels during the COVID-19 pandemic. The opening of these temporary shelter hotels provided an opportunity to test a new intervention. The hypothesis for the Beyond Housing program is that health and well-being outcomes can be improved by initiating supports for individuals while they are in the shelter hotel and continuing these supports once a client is connected to housing. As our country grapples with increasing pressures related to housing affordability and homelessness, the learning from this program offers potential options for communities, particularly large urban centres.

While we know there is inequitable access to palliative care across the country, it is particular challenging for people experiencing homelessness. Buchanan et al. (2023) highlight how critical this gap is, given that the average age of mortality for people experiencing homelessness is approximately half that of the general population. Palliative care is delivered in multiple settings, including hospitals, home and long-term care, but there are few examples of programs specifically designed to meet the needs of this population. The authors describe the impact of Palliative Education and Care for the Homeless (PEACH) – a clinical outreach program based in Toronto that aims to meet the needs of homeless and vulnerably housed people with life-limiting illnesses. Understanding how the partners have addressed some of the systemic barriers to serving this population offers valuable insight for the growth of similar programs.

One of the silver linings of the COVID-19 pandemic has been the rise of innovative programs and services to address the urgent needs of our most vulnerable populations. A community in Northern Ontario leveraged a mobile health clinic model using a Community Wellness Bus to provide low-barrier, non-judgmental services to individuals who are underhoused or living with a mental illness and/or addictions in the community and to help them re-engage with healthcare services. Dorans et al. (2023) describe the governance and partnership structure, the success factors and challenges of this program and how the Community Wellness Bus model could be successfully implemented in other small- to medium-sized communities in Canada.

As we see the increasing push for greater integration of care, Tajirian et al. (2023) share their learning and recommendations for improving the delivery of physical healthcare to individuals receiving care in mental health settings. The article highlights the need for increased attention on the suboptimal health outcomes and decreased life expectancy for individuals with severe mental illness related to a higher burden of physical health disorders and inequitable access to care. The authors note that given that virtually every healthcare organization supports individuals with severe mental illness, their findings offer important policy considerations and guidance for improvements to the quality of patient care. The underlying message is that the physical healthcare needs of people with severe mental illness should not be forgotten.

The Pandemic, in Black and White

We spoke with Heather Patterson about her extraordinary book, Shadows and Light (published by Goose Lane), that records through photographs and her own narrative the awful and heart-wrenching experience with COVID-19 in acute care. She vividly portrays the compassion and sacrifice of our hospital workers and professionals and the poignant experiences of patients with COVID-19 and their families. The HQ interview and her book offer an opportunity for reflection and a chance for all of us to recognize the underappreciated contributions of those working in our hospitals.

Approaches to Integrated Care

Over time, our healthcare systems have become increasingly complex and, recently, more and more stressed. As a result, having a primary care provider is not always a guarantee that a patient will receive appropriate and timely referrals to other, sometimes more specialized, services that they might need. Too often, patients have ended up in hospital emergency departments as a last resort. Mehrfar et al. (2023) describe a program that sets out to address this issue successfully: Seamless Care Optimizing the Patient Experience (SCOPE). It entails nurse navigators, real-time access to specialist advisors and local primary care leads. The program, initially developed and implemented in Toronto, has now been applied in a variety of suburban, small-town and rural settings, and it is attracting interest from Canadian provinces beyond Ontario, too.

Healthcare Procurement

Nearly 15% of hospital spending in Canada goes to one-time capital acquisitions, and in most hospitals these spending decisions are made considering only the initial capital cost and do not take into account the full lifetime costs, including operating costs. Abbas et al. (2023) present an insightful study of the desirability and challenges involved in adopting a total cost of ownership (TCO) approach to procurement. It concludes, convincingly, that the TCO approach gives decision makers a superior basis for decisions, but it represents a significant change and requires additional resources to administer.

ICES Report: Cancer Risk among Adults Living with HIV in Ontario

In our regular column from ICES, Nicolau and Burchell (2023) offer an analysis of comorbidity trends among adults living with the human immunodeficiency virus (HIV), particularly the rising rates of cancers with infectious causes. Their analysis points to the case for stepping up non-HIV-specific health screening, including cancer screening for patients living with HIV.

CIHI Survey: Access to Mental Health and Substance Use Services

The recent agreements between the Canadian federal government and its provincial counterparts have focused on several key care sectors under stress, including mental healthcare. In a push to increase accountability for improvements, CIHI has developed several new indicators to track access to mental health and substance use services. Sabad et al. (2023) describe this work in this issue's CIHI report.

Quarterly Reflections from Neil Seeman

Finally, Seeman (2023) gives us a remarkable take on social isolation and loneliness among seniors. He also identifies some innovative, out-of-the-box ways of addressing these concerns. It is a must-read piece for all those involved in care for the elderly and primary care, as well as those charged with developing policies in these sectors.

Write to Us

As always, please contact the HQ editorial team with your ideas for articles or themes that you think should be highlighted in the journal. With our healthcare systems facing such unprecedented stress, we embrace an “all-hands-on-board” approach to identifying new solutions and practices that will improve care and the experience of patients and their families.

– Anne Wojtak and Neil Stuart

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