Introduction Homelessness is a complex issue; it is always about a lack of housing, but other factors, such as inadequate income, tenant security, individual financial crises, health problems (including mental health and addictions), child abuse, trauma, a lack of social support, and involvement with law enforcement and the justice system are related to homelessness as well. The purpose of this paper is to highlight the health care services that are available to, and utilized by, the homeless population. This paper: describes the health services that are provided by local service agencies in Calgary, Canada, presents estimates from the literature of the cost or providing office- and hospital-based care, discusses some of the barriers faced by individuals experiencing homelessness when attempting to access health care services, and provides recommendations for improving the health outcomes and reducing hospital readmissions. Barriers to Accessing Care Homelessness itself can act as a barrier to accessing health care. People who are experiencing homelessness may not be able to access care due to competing needs and priorities, such as the need to find food, clothing, and a place to sleep. Most people have experienced trauma, so they may not trust health care providers or have the motivation to find care. A lack of access to transportation can make it difficult to attend appointments, and it is difficult to contact individuals for follow-ups and referrals if they do not have a mailing address or phone number. People with chronic conditions usually need medications but they may not be able to afford them, or they may not have a secure location for storing them. Providing proof of coverage (i.e. a personal health card) can also be an issue when accessing primary care. In addition, feelings of being unwelcome in health care settings and the stigma associated with seeking care for mental health and addictions issues can prevent some individuals from seeking health care in the future. Utilization of Health Care Services The high rates of health care utilization among the homeless population often manifest as visits to emergency departments rather than primary care. Individuals who are experiencing homelessness, especially chronic homelessness, are more likely to be admitted to hospitals than the general population, and once they are admitted, they tend to have longer stays as well. These individuals may be using emergency departments because primary care physicians may not be available, or they may face greater barriers to accessing primary care. One study found that the factors that predominantly influenced likelihood of going to an emergency department were less stable housing, chronic illnesses, and victimization. The Cost of Providing Health Care Not all individuals experiencing homelessness have the same health care costs. Individuals experiencing chronic homelessness account for a large proportion of the service utilization in health facilities and tend to have the highest health care costs, especially those who have severe mental health conditions. Other factors such as having alcohol or drug dependence and having spent a greater duration of time sleeping rough are also related to increased costs. Patients who are experiencing homelessness consume health care resources at a greater intensity per day than the general population, which results in greater costs, but this could be due to disease severity at admission; they may not seek care until they are experiencing a health crisis. [vi] Provision of Health Care By Service Agencies Many local non-profit service agencies provide health services to vulnerable populations in emergency shelters and community-based clinics. In Calgary, The Mustard Seed and CUPS are two such agencies that have clinics where they provide primary care. They are also able to offer allied and specialist health services, and support individuals with accessing other resources and services. The CAMPP team also operates out of the CUPS facility and provides palliative care to vulnerably housed individuals. Inn From the Cold is another service agency that specifically serves families. It is able to provide a very limited amount of mental health and primary care. Health Care Issues to Be Addressed Aside from primary medical care there are health services that are not adequately provided to the homeless population, such as oral and mental health services. Dental services are not publicly-insured; they require out-of-pocket payments, so people with low incomes might not be able to afford them. Many people go to emergency departments to seek care for dental issues, but those settings are not designed to provide that type of care. Similarly, mental health issues are the most common reason for emergency department visits among people experiencing homelessness. The deinstitutionalization of psychiatric hospitals was meant to move care into community-based settings, however, the community-based care was not developed, so emergency shelters and service agencies were left to care for those individuals and fill that gap. Emergency shelters, however, are not an appropriate alternative; they are meant to provide temporary housing, not health care services. Recommendations Health care providers should assess the housing status of patients as they are admitted to the hospital. For patients who require housing, social workers should attempt to find appropriate housing for the patients prior to discharge. Medical recovery or respite facilities can give patients a place to live when they are not well enough to be on the streets. Hospital staff should also refer patients in need of housing to local Housing First programs. Additionally, social workers’ notes should be made available in electronic medical records so they can be accessed by service providers in the community. There is also a need to improve access to primary care services. This can be done through the creation of mobile outreach or specialised services with staff trained to serve the homeless population, or through the establishment of patient-centred medical homes. Additionally, clinics could be created within hospitals to provide primary care or patients could be referred to Primary Care Networks. It may also be beneficial to have programs where shelters users are able to connect with peers with similar experiences and to have peer navigators in health care settings. Front-line staff should take a mandatory course about providing care using a trauma-informed approach. Researchers and policy-makers should create a common definition of homelessness and shared databases. The provincial government should determine whether/how community-based mental and oral health services can be financed. Finally, different orders of government should work with non-profit organizations, researchers, and individuals with lived experienced to find solutions for supporting the provision of health care services for the homeless population. Conclusion It may not be enough to implement only one strategy for providing health care to the homeless population; multiple approaches should be taken to address various concerns related to this issue.
Grewal, E. (2019). Health Care Services For People Experiencing Homelessness (Unpublished master's project). University of Calgary, Calgary, AB.