‘In Dialogue’ Episode 11: System barriers in caring for unhoused populations

Introduction:
CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.

Mark Sampson (MS):
Welcome to part two of our two-part conversation with Dr. Jonathan Wong. When discussing supporting unhoused populations, many people have referred to the idea that housing is a fundamental part of healthcare and without it, health concerns continue to worsen. In other words, housing is healthcare. It is critical to people’s success and health outcomes. What are your thoughts on this? Do you agree generally that a lot of where this can start is actually getting proper housing in place?

Dr. Jonathan Wong (JW):
I totally agree and agree that is a fundamental part. I think housing is indeed healthcare and helpful and really, without the safety and security of housing, it’s hard to work on one’s mental health or substance use or any other health concern, be it high blood pressure or diabetes. Unfortunately, as physicians, it’s not like I can write a prescription for housing. But I can certainly call on policymakers and governments to make housing more affordable, and provide an ample variety of housing options. But it’s obviously — I don’t know — it’s not that simple, though, right? It’s not just a question of affordability or increasing supply — supply, affordability, are definitely issues. But everyone is very different. We all have different priorities and circumstances, abilities to function independently. You can’t just plop someone into a house and expect someone to suddenly be completely independent and be able to maintain their housing. There also needs to be a plethora of resources available to support people who might need it post-housing.

So, I think typically, social workers, case managers, people who work to get people into housing, they might only support someone for like another three to six months. And you know, I don’t know, what does that mean, what are we doing? How are we facilitating safe transitions into housing? And how are we preventing re-homelessness? What is the criteria, as a case manager or housing worker, what’s the criteria to safely discharge? And I love case managers. I think they’re worth their weight in gold, or Bitcoin, or however you want to weigh them. But I know housing is very — in this day and age — it’s very hard to come by. And people always have the best choice. But I think, at least in some of the folks that I’ve worked with who have eventually gotten housing, they end up being uprooted from their community where their supports are, where their doctor and nurse practitioner and their community, their friends, their support network. And I feel like we always need to ask, “Well, what works for you? How can we put you in the best position to succeed and to maintain housing and not be evicted after a year or two?”

There’s someone that we recently met on street medicine, just sort of painting on the corner, who is actually housed. I have no idea how he managed to get housed, but our nurse did a home visit and his place is a mess. And I don’t know how much longer he’s going to last there. At what point are neighbours starting to complain about certain things? And, eventually, the person is going to get evicted. And the person is not currently supported by a case manager, but desperately needs one. So, there just needs to be more of that supportive housing style, resources available to folks, I think. Not everyone needs it, of course. But as I mentioned earlier, we need to think about what works for this person.

Another consideration for housing, and to the point of we can’t just plop someone in, but if someone is using substances too — similar to the earlier hotel shelter comment that I made, like people fatally overdosing in hotel rooms — if we put someone in there, in an apartment, are they at risk of fatally overdosing? Can we bring more addiction support to them locally? Are there safe injection sites nearby or on-site? If anything, the pandemic revealed that it’s not COVID-19 killing people — it’s the opioid crisis. It’s fentanyl. It’s extremely dangerous and toxic street drugs.

It’s all a challenge. Housing is definitely a part of it. I also wanted to comment on the ability to maintain housing and have your unit taken over. I’ve seen cases where someone gets housing and their unit gets taken over by other people, and they’re essentially locked out of their own home. But then because it’s their name on the rent, they’re the ones being eventually evicted. It’s housing, and how can we durably keep them keep folks housed and prevent re-homelessness?

MS: Switching gears a little bit to talk about the health care end of things. What role can physicians play in ensuring that these marginalized populations don’t fall through the cracks when they actively seek out health care, whether at a hospital or other facility?

JW: So, it’s all going to be harm reduction-focussed and trauma-informed. It’s not just the doctor themselves. Whatever roles physicians can play in terms of organizational change, in culture change, and training and coaching and informing people that you work with. Everyone should really have an understanding of these principles. Sometimes it takes great effort, and sometimes pains, to get someone into a tertiary care centre. And a lot of work gets done for this. And to have that — for instance, I had this or I’m still working with this particular patient, [who] has uncontrolled diabetes and diabetic foot ulcer and bone infection and absolutely needs to go to hospital, and there’s a lot of encouragement to get them there. And to have that derailed by someone who isn’t maybe as patient or can come off as judgey or dismissive, will absolutely cause some folks to leave without even being seen by a physician. I mean I get that emergencies are busy. Everyone is overworked and tired. And I’m definitely not disparaging anyone. But, I mean, just basic kindness, gentleness, respectfulness goes a long way in making people feel dignified. I don’t know if there’s any way to fast-track people. But, I think generally, anything that physicians — in their own practice, when seeing folks who are coming into hospital or as leaders in the hospital — can do to make people feel more comfortable.

Hospitals are often traumatizing places, as you know. Sometimes the sight of security can be triggering. Especially during the pandemic, no one was ever allowed, but I think sometimes people’s community and their friends or peers are not allowed to come if they aren’t family. But can we allow people’s friends to come, and visit and support them? There are a good number of places that have — like St. Michael’s Hospital, for instance, downtown — I don’t know what the title is, but they have folks who, in their emerg, specifically work with people who are experiencing homelessness or are more vulnerable, to make them more comfortable. And also, on their inpatient unit, they have these homeless outreach workers. I think all of these pieces are critical. And I think, as physicians, the transitions of care piece is also very key in preventing people from falling through the cracks. All too often, they’re — at least on the outside looking in. I mean, I don’t know that people are content to allow people to leave against medical advice, but it happens very often, unfortunately. Can hospitals change such that, if there’s capacity on your inpatient unit, can you leave your bed open for 24 to 48 hours to allow someone to come back? [Can] a homeless outreach worker be allowed to go and chase them down, and try and bring them back? Right? If someone’s using substances, can you be a little aggressive in your safe opioid supply prescribing, so long as it doesn’t interfere with whatever else is going on clinically?

There’s this addictions doctor at St. Mike’s, she is wonderful. And she’s also thinking about, well, how do I get this person a TV, the TV cable subscription in their rooms to make them more comfortable? Or do they need double portion meals? Do they need their insurers? Are they on enough safe opioid supply? All those things to make people feel comfortable, so that they don’t leave against medical advice ultimately.

I think I was getting into the transition of the care piece, but sometimes people get discharged with no clear plan. And as a primarily outpatient physician, it’s hard to follow on the outside and what’s been communicated. And when you talk to the patient, sometimes they’re like, “Well, no one really ever told me this or that.” And you read some of the discharge summaries, and it’s DC or discharged home. Did we ever even check on the patient’s housing status? If we knew that they were experiencing homelessness, how can we ensure that follow up doesn’t get dropped? And I know, usually, it’s the intake person that might take down phone number and email address or even their physical address. But, somehow, it doesn’t always get to the care team that, hey, maybe I do need to call someone shelter and get a little more collateral. And these things do happen, but sometimes it does, unfortunately, get missed in spite of our best efforts. I guess it’s usually that Swiss cheese model where multiple things happen and then a bad event happens.

MS: Do you know of any resources or support tools, maybe some training that might help physicians and institutions address these kinds of issues and create more welcoming, safer, more inclusive spaces for these patients who are especially vulnerable?

JW: I think it does come down to health human resourcing. I get that hospitals are so, so stretched, but I think this is an area that we definitely need to invest in as a system. And again, it comes down to where the government’s going to put their money.

MS: I know here at CPSO, we’ve done training modules as part of the Rainbow Health Network for treating LGBTQ2 communities and the San’yas cultural safety training for Indigenous communities. And these tools are incredibly helpful in just pivoting your thinking and really considering a number of issues that you may not have considered before in your work. But it sounds like we need something equivalent for homelessness and precariously housed populations, and all the rest of the kind of training that is able to really help people work through these issues and drive that kind of more welcoming and safe environment that you’re talking about.

JW: Yeah, totally agree.

MS: Yeah. What do you consider to be the greatest obstacle currently facing unhoused populations and how is it impacting their health?

JW: So, I would say probably poor policy and, broadly, the precariousness of our social safety net. I know we’re doing better than our U.S. counterparts. But you can have the most robust program designed on paper with the best health human resources out there, but if policies around housing, around income, if they don’t align to make it possible for people to escape poverty and homelessness, then even the most well-designed program will fail. So, as I mentioned, housing options need to work for people. I already mentioned without the safety and security of housing, it’s really hard to work on one’s health. And no matter how many medications I prescribe, the housing piece is crucial.

I think greater income supports, like ODSP, Ontario Disability Support Program, is really a drop in the bucket, particularly for folks who live in Toronto or one of the bigger cities in Ontario. I believe someone as a single person can take in $1,200 or so, $1,225 or something. But $700, around $700 is earmarked for basic needs, and then another $500 for shelter allowance. But if you are living outside, they aren’t going to give you the shelter allowance because you’re not staying in a shelter. So, all you’re getting is really $700 per month for your quote unquote “basic needs.” And given the cost of living here and inflationary pressures, there’s no way that that meets people’s basic needs. And I don’t think they really increase ODSP payments. And I think at one point they were talking about possibly making ODSP harder to come by, which would definitely be a backward step. So, all of these policy decisions have a very, very big and negative or can have a big and negative impact on people that we serve.

I think outside of the policy stuff, like I think addictions — I know you only asked for one — but addiction support is a big one. Even though, as I mentioned earlier, I think Toronto generally has trained up a lot of physicians to be able to provide more meaningful addiction support, but there’s still a big gap in that there are no medical detoxes available that are easy to get into. In general, the amount of need that there is in this area is just so, so, so fast and unmet. And, of course, if you are struggling with substance use, it is so challenging to engage in other aspects of your healthcare because a lot of time is basically spent obtaining, using and recovering from substance use. So, it’s just really sad to see and I’m not trying to — I hope I’m not painting a picture that every person who is homeless is a substance user. That’s definitely not the case. And just really wanting to stress that substance use is often, I would say all the time, used as a coping mechanism for this very, very extensive and terrible traumas that have happened to people over the course of their lives.

MS: I think that’s something that we’ve touched on in a couple other conversations that we’ve had about, again, it speaks to that judgment-free way of treating patients, and really meeting them where they are and understanding just the extent of that trauma and the various coping mechanisms that they’ve developed, whether that involves substance use or something else.

Any closing comments or thoughts for the future? What are some of the things that you hope for yourself, for your colleagues, for your patients and for our health system overall?

JW: I guess I just hope that we collectively, as healthcare providers, would see the moral imperative that we have to not neglect people who are living on the street or have had an experience of homelessness, and really work towards fighting all this stigma that people face. People are shamed and blamed for the choices that they make. But I think when it comes down to it, people are just making the best choice that they can given the circumstances that they’re in. I think we can all probably say that there’s a lot that we cannot individually control and it’s definitely true of folks who are experiencing homelessness. There’s a ton more that they can’t control and I just hope that we would be able to educate and inform and love on others. I think those things will combat ignorance or fear around working with people who are experiencing homelessness, because I think our greatest asset is really just the wisdom, the love that we can extend to folks and letting them know that they aren’t forgotten and that they are of inherent value as human beings. Some of the most beautiful and skilled and courageous and resilient and generous people I’ve met in my lifetime are people who have had or are currently experiencing homelessness.

MS: Well, I think that’s an incredible note to end on. I think that you’ve given us so much to think about, to consider, to pass along to colleagues in the health space, and armed us with some really important information that’s going to help us to move the needle and make improvements to the system that are going to help these populations. I think that’s something that we all hope we can do. And I really appreciate the time that you’ve taken to share these stories with us and your perspective on all this. It’s really quite something.

JW: Thank you so much for having me and it was so great to chat with you.

MS: Thank you so much. Hope you enjoyed part two of our conversation with Dr. Johnny. If you haven’t yet, please check out part one, which was released in November last year.

Closing:
Thank you for joining us. Please visit CPSO Dialogue for more in depth discussions about health care.