People who go to the hospital may visit the emergency department, receive treatment, and leave, or they may be admitted for longer term care. Admissions to hospital may be brief, such as for 24 hours, or they may be on-going over several days, weeks, or even months. The duration of the stay is often dependent on the nature of the condition and treatment that is needed. In the previous section we examined the use of emergency medical services among people experiencing homelessness and saw that while some individuals use these ambulatory services and emergency departments at a high rate, it is generally because of complex health issues.

After a period of time spent in the hospital, patients undergo a discharge process. In this section, we set out to learn more about what happens after patients experiencing homelessness are discharged from hospital. Before continuing through the material of this section, we invite you to pause and reflect upon this. Where do people go after leaving the hospital? How well can they manage the follow-up care instructions? What happens if they are unable to maintain their treatment plan on their own? You may use the space below to record your thoughts.

Discharge is a standard part of hospital administration that is guided by a set of protocols. Generally, a dedicated discharge planner, such as a Nurse or Social Worker, will meet with patients as they are preparing to leave the hospital. They will review the treatment plans and ensure the patient has information such as how to care for a wound, change their dressings, take the appropriate prescribed medication, and when to return for follow-up visits. For many patients, being discharged is a welcome process, as it indicates they are able to return home and continue their recovery in a setting that is more familiar. However, when a patient enters the hospital already experiencing homelessness – or loses their housing during their hospital stay – the process of discharge becomes more complicated.

We begin this section by looking at standard discharge practices, with a brief video from Sunnybrook Hospital in Toronto. This video is presented here to highlight how discharge unfolds for patients within the general population, who are housed. As you watch this video, we encourage you to take note of any issues that might arise for a patient if they were experiencing homelessness. Following this video, we present an activity in which we critically examine a standard instructional discharge paragraph, and highlight the areas where homelessness requires additional considerations.

Dr. Bill O’Grady: The need for improved hospital discharge practices

In this video Dr. William [Bill] O’Grady argues that more specialized education is needed for police and emergency room workers, who regularly interact with people experiencing homelessness. He notes that due to a lack of primary care, when people experiencing homelessness are injured, they often go to the emergency room for treatment. Prior to discharge, Dr. O’Grady says it is important that hospital workers ask these patients where they are going to go. In some cities, he notes, this work is formalized with a social worker located in the hospital specifically to assist these patients find housing. This video is 1:15 in length and has closed captions available in English.

In the best-case scenario, hospitals have people on staff who are able to follow the progress of patients experiencing homelessness, from the time they are admitted until they are discharged into secure housing. However, this best-case scenario is not the norm. Researchers in Metro Vancouver, for instance, conducted in-depth interviews with 40 housing and health care providers for older people experiencing homelessness and found they are often discharged to inappropriate locations, such as shelters, because of a lack of better options (Canham et al., 2018). The widespread lack of affordable housing stock across Canada means that people have limited options for where to go after they are released from hospital.

This section’s featured reading, entitled, “Nowhere to go: Exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto, Canada” takes a look at the factors that create discharge pressures in both the health care and homelessness sectors. Researchers conducted semi-structured interviews with 33 key stakeholders, including hospital workers, shelter workers, researchers, policy advisors, and advocates working in homelessness and health care (Jenkinson, Strike, Hwang, & Di Ruggiero, 2021). They found that historical and contemporary socio-economic contexts, such as declining financial resources, have resulted in a culture of efficiency within hospital settings, that prioritize accountability measures and create pressure to discharge patients as soon as they are medically stable (Jenkinson et al., 2021). Conversely, many shelters have adopted exclusion and eligibility policies to block the admission of people exiting hospitals, under the premise that they are not adequately prepared to manage their advanced health care needs (Jenkinson et al., 2021). These conditions create tension, as patients are not permitted to remain in hospital, but have nowhere else to go once released. As you engage with the featured reading below, we encourage you to consider the question of whose responsibility it is (or should be) to help people experiencing homelessness obtain secure housing upon their release.

Dr. Naomi Nichols: Discharging youth from the hospital to the parking lot

In this video, Dr. Naomi Nichols argues that we create public systems that imagine the user is housed, and those who are unhoused face challenges when navigating systems that were not designed with them in mind. As an example, Dr. Nichols cites people who are on a waitlist for mental health services but do not have a phone to be contacted when their place becomes available. She further cites stories from youth of being in hospital following an overdose episode and being discharged in an incapacitated state, early in the morning, to a parking lot, because assumptions were made that a parent would pick them up without verifying their family situation. This video is 2:09 in length and has closed captions available in English.

Dr. Tyler Frederick: Exiting hospitals into shelters

In this video, Dr. Tyler Frederick reflects on improved service alignment, in which systems like housing and health care would work better together. In past approaches, the hope was people would go to an emergency shelter and be able to receive the supports they need to move on to the next phase of their life. However, Dr. Frederick notes that the reality is often that people are doing the best they can in systems that are not always well aligned. For instance, people working in hospitals may not want to discharge patients into shelters but lack knowledge on the alternatives. This video is 1:49 in length and has closed captions available in English.

Most patients who enter the hospital are housed. As such, interactions between hospital staff and the homelessness sector are not a regular part of day-to-day operations. It is when a patient who is experiencing homelessness is admitted, and subsequently discharged, that this lack of regular interaction becomes problematic. The health care and homelessness sectors operate separately in many communities, having different budgets, decision-makers, and policies than one another. This can create barriers, such as when a person who is experiencing homelessness is about to be discharged and they have nowhere to go and no one to assist them.

The degree to which health care and homelessness sectors work collaboratively does vary across different geographic areas, with some hospital and shelter staff coordinating services more effectively than others. However, Jenkinson, Strike, Hwang, and Di Ruggiero (2020) have found that there are legal considerations, such as pertaining to health information protection laws, that create barriers to the “circle of care” that exists within a hospital being expanded to include shelter workers outside it. Other studies have supported this finding. For instance, a national survey of 660 stakeholders working in homelessness and health care roles found that the three main challenges for discharging patients experiencing homelessness were related to communication, privacy, and systems pressures (Buccieri et al., 2019). Communication issues resulted as people in both sectors were uncertain whom to contact as Dr. Frederick, a co-investigator in this study, explained in the preceding video. Privacy issues arose as homelessness sector support workers sought to provide or receive information about shared clients but were prohibited from doing so by health information laws. Finally, systems pressures existed within hospitals and shelters which are both often at (or near) full capacity without available beds (Buccieri et al., 2019).

The results of the national survey showed that communities across the country are struggling to support patients experiencing homelessness who are being discharged from hospital (Buccieri et al., 2019). Researchers conducting this study gave participants a series of statements about hospital discharge for patients experiencing homelessness and asked them how much they agreed that the statements applied within their community on a scale of 0 (not at all) to 100 (applies completely). The results, presented below, show quite clear agreement across the country that hospital discharge for people experiencing homelessness is a problem that needs to be better addressed, that improving discharge procedures could reduce chronic homelessness, people are generally discharged to the street and not to supportive housing, that hospitals and homelessness sector agencies do not generally collaborate well, and that these patients are not discharged with plans that are well-adapted to their unique needs (Buccieri et al., 2019).

The analogy of a revolving door is perhaps cliché, but also accurate in this situation. There are many reasons that people who experience homelessness return to hospital after discharge. As we have seen, they may not have anywhere to go and end up (best-case scenario) in a shelter or (worst-case scenario) on the street. They may also be discharged on their own, without the support of a person to pick them up or offer them assistance while they are recovering. At the same time, there are structural issues like a lack of communication, privacy issues, and systems pressures that get in the way of coordinated care. All of this creates the conditions for poor health outcomes.

These are all social determinants that give rise to medical complications. You may recall the study by Wolfstadt et al., (2019) that showed marginalized patients may be more likely to have complications following surgery. Consider a situation in which a person is discharged without housing and the local shelter is full or says it cannot accommodate them due to their medical needs. How well do you think that person will be able to follow post-discharge instructions, like changing surgical dressings, while sleeping in a tent under a highway overpass? How will they obtain the medical supplies needed to care for their wound? How hygienic do you think these conditions would be?

Environmental factors are just one reason post-discharge complications arise. People who experience homelessness often do not have adequate follow-up care. In the study about surgical referrals, Zuccaro et al., (2018) found that just under half (49%) of referred patients attended at least one outpatient appointment, and that only 34% were able to complete their full follow-up protocol. Likewise, Alunni-Menichini et al., (2020) have written that the lack of continuity complicates emergency response professionals’ ability to make referrals even more than issues related to coordination. The lack of post-discharge follow-up care results for many reasons. Health care providers may not have contact information needed to inform a patient about an upcoming appointment and if they do, the person may not have transportation to get there. It is also challenging to keep track of appointments when one lacks reminders, such as a wallet card, note on the fridge, or entry into a smartphone calendar. These missed appointments are another reason why medical complications arise, and post-discharge readmissions are more common.

As part of their treatment plans, while admitted and post-discharge, patients may be prescribed medication. Richler, Yousaf, Hwang, and Dewhurst (2019) have found that among vulnerably housed patients admitted to an internal medicine service of a tertiary care, inner-city hospital, the responses to medication were generally positive but that study participants also expressed concern about adverse side effects. While patients are admitted to hospital, they are under the care of a team who ensures they receive the required medication in the correct dose and on the appropriate schedule. However, after they are released, patients are expected to manage their own medication. Again, this is challenging for patients experiencing homelessness. From a practical standpoint, they may not have the money to afford medication, may lack a space to store them (particularly if refrigeration is needed), or they may forget to take them while trying to meet other basic needs like obtaining food (the lack of which can also cause complications with medication). Remembering to take medication may also be more challenging for people who also have mental illness and/or substance use issues.

Researchers who conducted interviews with 129 people experiencing homelessness who were admitted to hospital found that 27% were readmitted again following their discharge (Wang et al., 2021). They wanted to identify the reasons this occurred and found that being prescribed a higher number of medications at the time of discharge was associated with higher odds of being readmitted (Wang et al., 2021). Given the challenges of managing medication while experiencing homelessness, it makes perfect sense that the more medications a person is prescribed, the greater their chances of having complications arise. However, in this same study Wang et al., (2021) looked at factors that reduced the risks of readmission. They found that having an active case manager, having informal support such as friends or family, and sending a copy of the patient’s discharge plan to a primary care physician who had cared for that patient within the preceding year were all associated with lower readmission rates (Wang et al., 2021).

According to Canham et al., (2019), coordinating hospital discharge should begin right from the time of admission, so that a person’s needs can be identified, and planning can begin. In an article that summarizes the findings from their scoping review, these authors write, “Patients would benefit from increased collaboration between healthcare and shelter/housing service providers during this transition because the identified health needs may potentially be met by either sector depending on what the need is and where the patient is within the transition. Hospital and shelter/housing service providers should increasingly mandate shared accountability for the transition of persons who are experiencing homelessness from hospital to increase the likelihood that patients’ needs are identified and supported during this challenging time” (Canham et al., 2019, pg.542).

What a patient needs will vary depending on the individual, making person-centered care critically important. For some people, such as those experiencing homelessness with complex health problems and high service use, on-going case management, harm reduction services, and housing might be the most beneficial post-discharge supports (Fleury, Grenier, Cao, & Meng, 2021). For others time-limited case management may promote continuity of care through low-barrier access, connection to community supports, individualized services, and effective coordination (Lamanna et al., 2018). Further tailored approaches may involve critical time interventions, which have shown statistically significant changes in health care utilization, including inpatient and outpatient services, for people experiencing homelessness in Ontario (Reid et al., 2021).

Increasingly, novel programs have begun to emerge that address discharge planning for people experiencing homelessness by connecting patients with housing supports while they are hospitalized, and then following up with them over a period of time to ensure they receive the wrap-around supports they need. One such example is the Bridge Healing Program in Edmonton that uses hospital emergency departments as a gateway to temporary housing, providing residents of the program with immediate short-term housing before transitioning them into longer-term permanent housing (Wong et al., 2020). This program is characterized as having a strong team, numerous services, connections to permanent housing, and a unique ability to reduce repeat emergency department visits, lengths of stay, and health care costs (Wong et al., 2020).

In Toronto, the Coordinated Access to Care for the Homeless (CATCH) program was implemented to determine the impacts this tailored service might have on frequent emergency department use (Stergiopoulos et al., 2016). The CATCH program is a brief multidisciplinary case management intervention for homeless adults discharged from hospital in Toronto, Canada. Funded in 2010 by the local health authority, CATCH aimed to improve access, continuity of care, and health and service use outcomes for adults experiencing homelessness who are discharged from hospital (Stergiopoulos et al., 2017). In total, 225 CATCH program users were enrolled in the study and completed quantitative survey measures at program entry to assess key health and social outcomes using a pre-post cohort study design. Follow-up assessments took place at 3- and 6-months (Stergiopoulos et al., 2017). In the pre-post analyses, CATCH participants showed statistically significant improvements in mental and physical health status and reductions in mental health symptoms, substance misuse, and the number of hospital admissions (Stergiopoulos et al., 2018).

Dr. Stephen Hwang is a general internist at St. Michael’s Hospital in Toronto, who has also worked on the CATCH program. In the video that follows, he speaks about the challenges of discharging people experiencing homelessness and about his new work with the Navigator Project, that supports patients from admission, through discharge, and 90 days beyond.

Dr. Stephen Hwang: What happens after patients who are experiencing homelessness are discharged from hospital?

In this video, Dr. Stephen Hwang reflects on his work as a General Internist at a hospital and explains that patients who experience homelessness sometimes have unique care challenges that hospital staff may not be accustomed to addressing. For instance, these patients leave against medical advice and are readmitted at higher rates than average. He notes that while well-intentioned, discharge and post-care plans for patients experiencing homelessness may not be well suited for very practical reasons, such as the need to keep track of appointments, have transportation, access medical supplies, engage in follow-up care in a shelter setting, and that patients may also have addictions or substance use issues. Dr. Hwang argues that hospital staff are kept busy with patients in the building and are less aware of what happens after a patient leaves. For this reason, his team has implemented a Navigator approach, in which a case manager meets an unhoused person at admission, develops a relationship, and follows-up for 90 days post-discharge to ensure they are receiving the supports they need. This video is 4:38 in length and has closed captions available in English.

We began this chapter by looking at how standard hospital discharge protocols are designed with some key assumptions, about the patient’s access to housing, resources, and social support. However, when a person experiences homelessness their discharge may be complicated by the lack of these factors. We have seen throughout this chapter that people who experience homelessness often have complex health issues and that, while not all individuals use hospital emergency services at a high rate, there are some individuals who do require frequent visits and hospital admissions. People may enter the hospital already experiencing homelessness or they may become homeless through a loss of housing while they are admitted.

When people who are experiencing homelessness are discharged from hospital, they often have nowhere to go. Economic and social influences within hospitals create pressure to focus on efficiency and high turnover, leading to discharge as soon as the patient is medically stable. However, at the same time, shelters face strains from operating at capacity and not being able to care for people who have advanced medical needs. The lack of affordable housing across the country creates the worst-case scenario, in which people are discharged with nowhere to go. The high rates of social exclusion also mean that people who are discharged while experiencing homelessness may not have friends or family to assist them. Individual workers within hospitals and shelters often want to do what is best for these patients, but are limited by structural issues like communication challenges, patient privacy laws, and systems pressures. The results of a national survey showed that these struggles exist in communities across the country.

After discharge, people who experience homelessness are more likely than housed individuals to have medical complications and need to be readmitted. These complications may arise from a range of factors, such as the lack of a secure and hygienic place to tend to one’s wound care, addictions and/or mental health issues that make following a care plan more difficult, challenges with attending post-discharge appointments, and complications from accessing, storing, and taking medication. All of these factors can create barriers for people experiencing homelessness, resulting in higher rates of readmission to hospital.

While there are many issues identified in the research literature, there are also some novel programs that were identified. Notably, Dr. Stephen Hwang and Dr. Cheryl Forchuk spoke about their initiatives in Toronto and London respectively, that start planning for discharge when a patient is admitted and use the time of their hospitalization to connect them with housing and supports. After discharge, patients are then continually supported for a period of time to ensure they remain stably housed and medically well. These programs offer a new way of thinking about discharge processes that are tailored to the unique needs of people experiencing homelessness and offer long-term support beyond the walls of the hospital.