Summary
We began this chapter by noting that people who experience homelessness often lack equitable access to primary health care, which can increase their reliance on emergency medical services. As housing is a key social determinant of health, we wanted to explore the relationship between homelessness, medical services, and hospital usage.
At the start of the chapter, we introduced you to the composite character Mia who visited the emergency department but did not receive the treatment she needed. This scenario was presented as an entry point into thinking about the complexity of homelessness and emergency medicine. We returned to her story again at the end to demonstrate how it can help us understand the foundational concepts of being trauma-informed, person-centred, socially inclusive, and situated within the social determinants of health as critical for understanding homelessness in Canada
We asked you to consider three questions along the way, with the guidance of leading homelessness researchers.
First we asked, “Do people who experience homelessness use emergency medical services at a high rate?” We noted that while this may seem like one of the simpler questions posed throughout this book, it is actually deceptively complex. In posing the question, we found that some (but not all) people who experience homelessness use emergency medical services at a higher rate than housed individuals. However, we also found that they do so because they lack equitable access to primary care and have multiple chronic health conditions. Use of emergency medical services may actually be a last resort for many individuals experiencing homelessness, particularly if transgender, living with mental illness, and/or if they have substance use issues, because of the stigma and discrimination they often face in these settings. As an alternative to hospital care, some emergency medical professionals engage in outreach to meet people in the community. This is no doubt a valuable service, but it does not negate the need to make our health care systems more accessible and equitable for all community members.
Next we asked, “What happens after patients who are experiencing homelessness are discharged from hospital?” This led us to consider what happens to people who are admitted to hospital once they are ready to leave. We found that standard discharge protocols are based on assumptions, such as that the patient has a place to recover, resources at their disposal including transportation, and someone who can care for them. Within the context of patients experiencing homelessness, a lack of housing and supportive relationships can be complicating factors. We learned that there are communication barriers, privacy laws, and systems pressures that make discharge a challenging issue across the country. Further, medical complications mean that many people who are discharged end up being readmitted to hospital within a short period of time. Fortunately, there are some unique programs that are operating to identify patients experiencing homelessness as they are admitted to hospital, and that help connect them with housing and continued supports after they are discharged. With more widespread uptake, these programs could have a real impact in helping people become housed and avoid future hospitalizations.
Finally, we asked, “Would improved funding for affordable housing decrease the burden on hospitals?” This question was prompted by a commentary piece discussing an initiative in New York City to divert public health dollars into housing initiatives. We found that there is a well documented link that shows housing is a key social determinant of health. The question of whether housing should be funded to reduce health care costs, however, was much more contentious. We found that the governmental structure in Canada creates barriers that de-incentivize Ministries from funding areas outside their mandate. We also saw that the research paints a complex picture, in that sometimes when people become housed they initially use less health care, and sometimes they use more. Further study is needed to understand the complexity of this relationship. While housing and health care are related, the exact mechanisms remain unclear. We concluded this section by considering Housing First as a critically important intervention that can have cost benefits but is better understood as having cost balances. In the end, whether housing has an impact on hospital usage, and its associated costs, is less important than focusing on the need to end homelessness because housing is a fundamental human right.
