2. What specialized primary care would people who experience homelessness benefit from?

One of the main takeaway messages from the previous section is that people who experience homelessness generally lack access to primary care, for a range of reasons, despite often having complicated chronic health conditions. Based on what you have learned so far, we would like to challenge you to put yourself in the position of a health care provider who is treating a patient experiencing homelessness. What specialized primary care do you think your patient might benefit from? We encourage you here to consider not only physiological care, but social care as well. What could you do to provide this patient with the best care possible so that their needs are met and so that they feel heard and respected?

Use the space below to record your thoughts on how you might approach a care plan for a patient experiencing homelessness who presented to you in a primary care setting. You may record as few or as many ideas as you wish in thinking about how to provide specialized primary care to a patient experiencing homelessness.

 

How to complete this activity and save your work: Type your response to the question in the box below. When you are done answering the question navigate to the ‚ÄėExport‚Äô page to download and save your response. If you prefer to work in a Word document offline you can skip right to the Export section and download a Word document with this question there.

 

Consider this conundrum: Homelessness creates health problems and then serves as a barrier to receiving adequate and timely health care treatment for them. This is evident from the research. For instance, many people who experience homelessness walk around during the day in ill-fitting shoes without being able to take them off or change their socks. Researchers who used a screening tool to assess foot conditions in a sample of 65 adults experiencing homelessness in British Columbia found that the rates of foot conditions were so high that foot assessments should be implemented as part of standard care for this population, to avoid health complications, hospitalization, limb removal, and disabilities (D’Souza, Mirza, & Karkada, 2021).

 

People experiencing homelessness have also been found to have high rates of hearing impairment compared to the general Canadian population, which might occur because people are unaware that benefits cover the cost of hearing tests (Noel et al., 2020). Research from Toronto with 132 people experiencing homelessness also showed there were substantial otolaryngology needs, pertaining to abnormal findings on head and neck examinations, such as nasal fracture and/or nasal obstruction (Wu et al., 2020). Shelter-based assessments in Toronto found that among 143 randomly selected individuals, ophthalmological disease burden was high, particularly related to low income and low educational attainment, and that this population is not receiving adequate tailored vision care (Jiang et al., 2020). The majority of vision care problems in Canada can be corrected with prescription glasses, indicating that a high rate of visual impairment among this population points toward barriers in access to care (Asare, Wong, Maurer, & Nishimura, 2019).

 

Researchers in Toronto looked at the relationship between dental problems and chronic health problems in a sample of 575 adults who were experiencing homelessness, had mental illness, and were part of the At Home / Chez Soi Housing First evaluation in Toronto (Mejia-Lancheros et al., 2020a). They found that among their sample, 43% had dental problems, which were positively associated with also having heart disease, diabetes, chronic bronchitis, stomach or intestinal ulcer, inflammatory bowel disease, migraine, arthritis, kidney / bladder problems, and iron-deficiency anemia (Mejia-Lancheros et al., 2020a). The more chronic health problems a person reported, the more likely they were to have dental problems, indicating that there is a relation between dental health and overall health, and that dental care should be better integrated into social and health care programs for this population (Mejia-Lancheros et al., 2020a). A model pathway to oral health care for people experiencing homelessness needs to incorporate government-sponsored oral health programs, support tailored to homelessness, oral health outreach initiatives, and professional education for care providers (Mago, Brondani, MacEntee, & Frankish, 2018).

 

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The research on health conditions and barriers for people experiencing homelessness is extensive. For instance, people who experience homelessness, particularly if using drugs and/or have severe mental illness, are at disproportionate risk of acquiring Hepatitis C virus (Nikoo et al., 2019), yet a scoping review of the literature indicated there is very limited research on how these individuals feel about testing and treatment (Palayew et al., 2018). Cardiovascular disease affects people experiencing homelessness at rates that exceed housed individuals and is a major cause of death among this population, but managing the condition is challenged by barriers to medication adherence, communication, and timely follow-up (Baggett, Liauw, & Hwang, 2018). In Saskatoon researchers looked at enhancing access to physical therapy services for people who were experiencing poverty and homelessness and found that they faced diverse barriers related to transportation, cost, wait times, and geographic location but that enhancing access by providing physical therapy services in a primary health care community-based setting had positive impacts on the study participants’ overall health, functioning, and wellness (Oosman, Weber, Ogunson, & Bath, 2019).

 

Living in Canada, the risk of hypothermia is a real concern for people who are experiencing homelessness, particularly if spending extended lengths of time outside. In a Toronto based study, researchers found 79 injuries and 18 deaths with hypothermic events between 2004 and 2015, amongst people experiencing homelessness (Zhang et al., 2019). This study further indicated that the odds of a hypothermic event increased with every 5 degree Celsius decrease in the minimum daily temperature and with every 1 mm increase in precipitation (Zhang et al., 2019). While we often see temporary emergency shelters open when there is an extreme cold advisory, this study actually demonstrated that most cases occurred during periods of low to moderate cold, with 72% occurring when the minimum daily temperatures were above -15 degrees Celsius (Zhang et al., 2019). These findings suggest that special considerations are needed to help prevent hypothermia in cold weather, particularly in the periods where the temperature has dropped below freezing but has not reached a cold enough level to trigger the opening of warming centres.


What do you think?

human head with light bulb as brain graphicFor people who are securely housed, the weather might pose nothing more than an annoyance. It might be a snowy day that requires clearing the driveway or a rainy day that requires using an umbrella to get to work. When we think about homelessness, the weather takes on another level of urgency. People may freeze to death in the winter and get sunburned or heatstroke in the summer. Opening warming and cooling centres offer only temporary relief. What are some longer-term solutions we could implement to protect people from living and sleeping outside? Can you see the direct connection weather highlights between the need for housing and improving people‚Äôs health? 


Clearly, there are many varied specialized primary care needs for people experiencing homelessness. We can see from this body of research that homelessness can lead to chronic health conditions, like dental disease, foot problems, head and neck problems, vision problems, and hypothermia among many others. Homelessness then also creates the barriers to treatment, such as by making it difficult to get transportation to appointments, have ongoing communication with primary care providers, take medication at scheduled times, and adhere to complex medical treatment plans. A significant amount of this published research comes from Dr. Stephen Hwang and his associates. We asked him, as a medical Doctor who works with patients experiencing homelessness, about specialized primary care. He explained that the clinical treatment of these conditions does not change with homelessness, but that relational practice does. Listen in as he discusses this in the next video. 

 

Dr. Stephen Hwang: Relationship-building in medicine with patients experiencing homelessness

In this video, Dr. Stephen Hwang explains that people often ask him whether there is something special about the treatment of health conditions for patients experiencing homelessness. He notes that while there are factors that might complicate treatment or add additional considerations, the basic treatment principles remain the same. Dr. Hwang argues that clinicians need to work with their unhoused patients to identify potential barriers to managing their illness and collaboratively find solutions. He further notes that clinicians should realize it is not necessarily the technical aspects of care that are different, but rather the relationship with the patient that requires the most attention. Dr. Hwang concludes that medical training focuses more on learning the treatments for conditions but should also include aspects of relational care, such as building trust and considering how patients feel in these interactions. This video is 2:29 in length and has closed captions available in English.

Key Takeaways ‚Äď Dr. Stephen Hwang: Relationship-building in medicine with patients experiencing homelessness

  1. People often wonder whether there is something special about the clinical treatment of health conditions for people experiencing homelessness. While there are factors that might complicate the treatment and management of illness, the basic clinical principles remain the same.
  2. The first key issue a clinician needs to keep in mind is what barriers exist that a person might face in managing their illness and getting the care they need, and how the patient and clinician can work together to overcome the barriers.
  3. The second key issue is realizing that it is not necessarily the technical aspects of care that are different, but rather the relationship with the patient that requires the most attention.
    • The relational aspects of care are discussed more in nursing than in medicine. Medical training focuses on learning how to treat conditions with medications, surgical approaches, and preventive medicine.
    • Medical training should also pay attention to how practitioners make patients feel when they talk to them, how they relate to patients, and whether patients trust them. These are particularly important with patients who are unhoused.

 

The best-practice approach to providing primary care to patients experiencing homelessness or housing vulnerability differs from mainstream clinical practice. As Dr. Hwang has noted, the treatment of the conditions themselves may be the same but the barriers the patient experiences require a tailored approach. To help health care providers, a team of researchers, practitioners, and people with lived experience have developed a document entitled, ‚ÄúClinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience.‚ÄĚ We invite you to pause here and read the guideline and then listen to the Canadian Medical Association Journal podcast, in which some of the team members discuss this important document.


Featured Reading:

open book graphicPottie, K., Kendall, C. E., Aubry, T., Magwood, O., Andermann, A., Salvalaggio, G., Hwang, S. W., Stergiopoulos, V., & Tugwell, P. (2020). Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. Canadian Medical Association Journal (CMAJ), 192(10), E240‚ÄďE254. 


 

In the featured reading Pottie et al., (2020) provide clinical guidelines for people who have past or present experiences of homelessness or housing vulnerability. They note that clinical assessment for these patients must take into consideration the person’s gender, age, Indigenous heritage, ethnicity, and history of trauma. They apply a social determinants of health lens, and argue that permanent supportive housing and income assistance are needed for patient wellness. They also indicate in their guidelines that case management interventions, that include mental health and/or addictions supports are recommended as an initial step to support primary care. When asked about implementing the guidelines 86 stakeholders, including 16 with lived experience of homelessness, rated the drafted recommendations in a favourable way (Magood et al., 2020).

 

The clinical guidelines are an important document for helping us think about how to provide equitable primary care to people experiencing homelessness in a way that is tailored to their needs. For instance, we have seen that traditional health care settings may be exclusionary to people who identify as LGBTQ2S+. Health care providers can provide meaningful care to transgender individuals, who experience high rates of violence, discrimination, and homelessness, if they recognize that addressing homelessness and the social determinants of health requires long-term engagement and interdisciplinary team support (Abramovich, Lam, & Chowdhury, 2020). In the video that follows lead author of this study, Dr. Alex Abramovich, discusses this research.

 

Dr. Alex Abramovich: Improving access to, and education about, health care for trans patients

In this video, Dr. Alex Abramovich explains that trans individuals are medically underserved, and experience poor mental health outcomes and high rates of disease burden compared to cisgender individuals. He notes that trans people often face violence and discrimination, leading to higher rates of suicidality, substance use, depression, and anxiety, with limited support available. Dr. Abramovich argues primary care needs to focus more on providing specialized health clinics for LGBTQ2S+ persons, as it is important to have a doctor who understands your needs and to whom you do not have to explain your identity. Dr. Abramovich concludes that further education and training about LGBTQ2S+ health is needed for people working in health care settings. Rather than relying on patients to provide this information, practitioners should seek out opportunities to learn more within their community and through online resources. This video is 4:51 in length and has closed captions available in English.

Key Takeaways ‚Äď Dr. Alex Abramovich: Improving access to, and education about, health care for trans patients

  1. Trans individuals are medically underserved. They experience poor mental health outcomes and high rates of disease burden compared to cisgender individuals.
    • Higher rates of suicidality, substance use, depression, and anxiety often stem from stigma, discrimination, and violence directed against them as well as not being able to access health care.
    • Trans individuals are often made to not feel comfortable in public spaces, such as being denied access to a public washroom. The stress of these encounters adds up and when people seek support there is nowhere for them to go.
  2. Primary care needs to focus much more on providing specialized health clinics for LGBTQ2S+ individuals.
    • It is important to have a doctor who understands your needs and experiences, and to whom you do not have to explain your identity.
    • It is a common experience for trans people who seek medical care for something not related to their transition, to have to continually answer questions about their identity.
  3. We need more education and training for practitioners related to LGBTQ2S+ health care. There are many resources available, both in communities and online.
    • The responsibility to become educated rests with the practitioner. It should never be up to the patient or client to provide that education.

 

aqua icon for website linkWant to learn more about LGBTQ2S+ health care?

Check out these helpful online resources as a starting point.


Primary care for people experiencing homelessness needs to account for the range of challenges and barriers these patients commonly experience. For instance, while workplace injuries may occur for housed individuals, the nature of the work may be different for people experiencing homelessness. In a study of cisgender and transgender women involved in the sex trade, 90% reported at least one lifetime traumatic brain injury and all reported one or more head injuries related to violence in sex work (Baumann et el., 2019). Participants in this study spoke about the stigma and discrimination they felt in health care settings, which served as a barrier that could be improved with enhanced training in anti-oppressive care practices (Baumann et al., 2019).

 

Traumatic brain injury is a common occurrence for people who experience homelessness, often rooted in their childhood. Song et al., (2018) examined the relationship between childhood trauma and traumatic brain injury amongst a sample of 487 individuals experiencing homelessness in British Columbia. They found 64% had traumatic brain injury and 88% reported childhood trauma including physical abuse (58%), physical neglect (63%), sexual abuse (46%), emotional abuse (62%), and emotional neglect (55%). Their analysis of how these variables are inter-related found that experiences of trauma, physical abuse, or emotional abuse in childhood were associated with having a history of traumatic brain injury (Song et al., 2018). These researchers also found that people who had 4 different types of childhood trauma were significantly more likely to have traumatic brain injury, indicating that negative childhood experiences can have a compounding effect on one’s risk of traumatic brain injury in life.

 

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Traumatic brain injury can result for many reasons. You may have heard the story of Stanley Cup champion Joe Murphy whose brain injury played a role in his experience of homelessness, pain management attempts, and mental illness. As you watch this brief investigative video from W5 entitled, ‚ÄúThe rise and fall of a Stanley Cup champion,‚ÄĚ we encourage you to think about it from a Primary Care and Nursing perspective. In particular, think back to the start of this section when we asked you to identify a care plan for a patient entering your clinical practice. Imagine now that patient was Joe Murphy. 

 


What do you think?

human head with light bulb as brain graphicAt the beginning of the video, we encouraged you to think of yourself as Joe Murphy‚Äôs Physician or Nurse Practitioner. What medical conditions did you identify that need to be addressed? What social determinants of health emerged to situate his care in a broader context? How would you provide him with the best primary care possible, given his complex set of needs? 


Housing First is one effective strategy for helping people with traumatic brain injury become stably housed. A study of 381 participants in the Toronto At Home / Chez Soi study, discussed further in the chapter on Politics, Policy, & Housing in Canada, found that Housing First participants had a significantly lower number of physical violence-related traumatic brain injury events, suggesting Housing First could be a targeted approach to help address this cause of traumatic brain injury (Mejia-Lancheros et al., 2020b).

 

The research evidence clearly shows that people who experience homelessness often have complicated health conditions that are not adequately addressed by mainstream health care approaches. One study in Montreal examined men’s ability to self-manage chronic health conditions within the context of homelessness and found that while they were generally confident in their abilities, their preferred mode of support was through consistent contact with health care providers and peer-support workers (Merdsoy, Lambert, & Sherman, 2020). The complexity of the health conditions, combined with the challenges of homelessness, makes it imperative for these individuals to have consistent health care. Ideally, this health care should be integrated in a way that meets their needs by offering specialized services that enhance continuity of care without requiring they go to multiple practitioners (Gentil, Grenier, Bamvita, & Fleury, 2020). Dr. Stephen Hwang discusses the importance of health care providers working together to support one another and provide the best patient care experience.

 

Dr. Stephen Hwang: What specialized primary care would people who experience homelessness benefit from?

In this video, Dr. Stephen Hwang reflects on the combination of biomedical technical expertise and philosophical orientation towards helping that health care providers need to work in specialty care for populations experiencing homelessness. He notes that having a group of providers who are like-minded is important for practitioners to avoid burnout and have others to discuss challenging clinical situations with. Dr. Hwang concludes that it is important for all primary health care providers to have strong links to specialty care hospitals, as patients who experience homelessness often require hospitalization and/or specialty care. This video is 2:12 in length and has closed captions available in English.

Key Takeaways ‚Äď Dr. Stephen Hwang: What specialized primary care would people who experience homelessness benefit from?

  1. The cadre of health care practitioners who work with patients experiencing homelessness need to have both the biomedical technical expertise and a philosophical and personal orientation towards helping people who are experiencing homelessness, disadvantage, and discrimination.
  2. Having a group of providers who are like-minded is important because it is difficult to do this work as a solo practitioner.
    • Having a community of practitioners that supports and provides back-up is important to avoid burnout and assistance in difficult clinical situations.
  3. It is important for primary care providers to have strong links to specialty care hospitals because people experiencing homelessness are frequently hospitalized and/or in need of specialty care.

 

Improving patient satisfaction with their health care can involve promoting more tailored primary care programs that are adapted to the needs of patients with lived experience of homelessness (Gentil et al., 2020). Health care providers, like Family Physicians and Nurse Practitioners, can help by identifying which of their patients are experiencing homelessness or housing vulnerability, taking steps to help them connect with case managers, and working collaboratively using trauma-informed and anti-oppressive approaches (Andermann et al., 2020). We conclude this section, on what specialized primary care is needed for people experiencing homelessness, with a reminder from Dr. Naomi Thulien that what these patients need is the same as what all patients need ‚Äď holistic team-based care in an environment that is beautiful, comfortable, and inclusive.

 

Dr. Naomi Thulien: What specialized primary health care would people who experience homelessness benefit from?

In this video, Dr. Naomi Thulien argues that we sometimes ask ourselves what people experiencing homelessness need, but we should realize that it is the same as what everyone needs. In primary care, that means a holistic team-based model comprised of Nurses, Social Workers, and Physicians located in a beautiful, comfortable, and accessible setting. Dr. Thulien elaborates that health care appointments should be longer to allow for urgent care matters to be addressed, as well as preventive discussions and measures around the social determinants of health. This video is 2:32 in length and has closed captions available in English.

Key Takeaways ‚Äď Dr. Naomi Thulien: What specialized primary health care would people who experience homelessness benefit from?

  1. Sometimes when we talk about people experiencing homelessness, the question is framed as, ‚ÄėWhat do they need?‚Äô They need the same things that everyone needs.
  2. Primary care for people experiencing homelessness should be done using a holistic team-based model that includes Nurses, Social Workers, and Physicians.
  3. The location of health care settings is important. The environment should be beautiful, comfortable, and accessible.
  4. Appointments within these settings should be longer, to not only address urgent patient needs but also to look at the social determinants that are leading to poor health.
    • Longer visits would allow more time to focus on prevention efforts, such as asking about tetanus shots, pap tests, and mammograms which patients may not have had done in several years.

 

We began this section by asking you to think about specialized primary care and how you, as a Family Physician or Nurse Practitioner, might apply your knowledge to care for a patient experiencing homelessness. We discussed a broad range of research literature to demonstrate the complexity of primary care needs and heard from Dr. Stephen Hwang that while the treatment plans are the same as for housed patients, it is the relational aspects that are different. We invited you to read and learn about a document outlining guidelines for clinical care of patients who are experiencing homelessness or housing vulnerability. It is important that this work be taken up in a way that is patient-centred, trauma-informed, and inclusive.

 

Specialized primary care requires that we consider the needs of individuals and tailor the care they receive to those needs. For instance, we saw how transgender individuals often receive care that is not appropriate or informed, which has detrimental effects on their well-being. We considered the role of sex work, violence, and early trauma as factors that account for the high rates of traumatic brain injury among people experiencing homelessness and examined a case study of Stanley Cup champion Joe Murphy. Finally, we saw that the best approach is one in which people receive team-based integrated care, so that their needs are met without having to go to multiple different locations. We ended on the idea that what people experiencing homelessness need from their primary care providers is fundamentally the same as what everyone needs, and that is to feel respected, included, and heard.

 

Podcast: What specialized primary care would people who experience homelessness benefit from? (12:56)

Click the link below to listen to all of the researchers answer the question ‚ÄúWhat specialized primary care would people who experience homelessness benefit from?‚ÄĚ in audio format on our podcast!

 


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Understanding Homelessness in Canada Copyright © 2022 by Kristy Buccieri, James Davy, Cyndi Gilmer, and Nicole Whitmore is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.

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