Health care providers should recognize that any effective strategy to address homelessness needs to include both interventions to improve the health of homeless individuals as well as larger-scale policy changes, according to a paper published today.
"It is essential to recognize that homelessness is equally the result of structural factors within a society, such as systematic inequities in educational and employment opportunities, a shortage of affordable housing, and social policies that are targeted against marginalized populations," said Dr. Stephen Hwang of St. Michael's Hospital.
Dr. Hwang's paper was published today in The Lancet, half of a two-part series on homelessness in high-income countries. Dr. Hwang, a general internal medicine physician and a researcher at the hospital's Centre for Research on Inner City Health, is one of the world's leading experts on health and homelessness. He also holds the hospital's Chair in Homelessness, Housing and Health, which is believed to be the first hospital-based chair in homelessness in the world.
As many as 3.5 million Americans and 200,000 Canadians experience homelessness every year, and the numbers are rising. Homeless people "are the sickest in our society," but just treating ill health might not be enough to help get people off the streets, according to the author of the first Lancet paper, Seena Fazel, professor of forensic psychiatry at the University of Oxford.
The series highlights that being homeless is not only bad for a person's physical and mental health but also has dramatic effects on life expectancy. Previous studies by Dr. Hwang and others have found that homeless people use the most expensive acute health care services, such as accident and emergency care, and need longer hospital stays than people with homes.
The Lancet series says that while government targets to improve the health of homeless people should be introduced (e.g. for the identification and management of infectious diseases, mental illness and diseases of old age), health care providers should also advocate for changes to the social policies and structural factors that result in homelessness, including the lack of affordable housing and employment opportunities for low-skilled workers.
The papers note there are some programs in high-income countries bridging the gap between homelessness and health services, such as the Housing First programs that provide housing and support services for homeless individuals with severe mental illness or substance abuse problems. Dr. Hwang is the principal investigator in Toronto for the At Home/Chez Soi project evaluating Housing First in Canada.
Medical respite programmes for homeless patients leaving hospital reduce the risk of readmission and the number of days spent in hospital.
St. Michael's also has two interventions aimed at helping people with unmet, complex health care needs access health resources in the community: CATCH-Homeless and CATCH-ED, specifically for people who use Emergency Departments five or more times a year, at least one of those times for a mental health and-or addiction problem. CATCH case managers work with family physicians, psychiatrists and other service providers to support patients' access to such things as medical care and mental health and addiction services
However, these examples are not the norm and much more needs to be done, said Dr. Hwang.
"It needs to be recognised that preventing homelessness, by creating more opportunities for housing, work, education, and health care during high risk periods, such as being discharged from institutional care, psychiatric hospital or prisons to the community, could effectively reduce homelessness and makes sound economic sense."
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