Abstract
Objectives
A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts.
Methods
Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare.
Results
Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging.
Conclusion
Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.
Résumé
Objectifs
L’un des principaux éléments des sorties d’hôpital consiste à trouver pour la patiente ou le patient une destination qui répond à ses besoins post-hospitalisation. Au Canada, il est difficile d’atteindre cet objectif pour les patients sans abri, qui se retrouvent souvent dans la rue ou dans des refuges à leur sortie de l’hôpital. Nous avons cherché à savoir pourquoi et comment la capacité du personnel hospitalier de trouver des destinations appropriées pour les patients sans abri à leur sortie de l’hôpital est influencée par des contextes sociaux et économiques dynamiques.
Méthode
Guidées par le réalisme critique, nous avons mené des entretiens en profondeur semi-structurés avec 33 participants : des membres du personnel hospitalier des services de médecine générale de trois hôpitaux urbains; des membres du personnel de refuges; et des chercheurs, des conseillers en politiques et des porte-parole travaillant au croisement des services aux sans-abri et des soins de santé.
Résultats
Les contextes sociaux et économiques historiques et contemporains (p. ex. les compressions budgétaires) ont déclenché l’adoption de mesures d’efficience et de responsabilisation dans les hôpitaux, et de critères et de règles d’exclusion dans les refuges, deux éléments que nous caractérisons comme étant des mécanismes dans le présent article. Les hôpitaux sont contraints de donner leur congé aux patients dès que ceux-ci sont jugés médicalement stables, mais ils ont du mal à les envoyer dans des refuges, car pour prévenir les sorties inappropriées, certains refuges ont adopté des règles et des critères d’exclusion et d’admissibilité. Ces mécanismes expliquent en partie la difficulté de trouver une destination appropriée pour les patients sans abri à leur sortie de l’hôpital.
Conclusion
Nos résultats font état d’une lacune systémique dans le parcours des sorties d’hôpital : les personnes sans abri qui n’ont plus besoin de soins de courte durée n’ont aucun endroit où aller, mais leurs besoins sont trop complexes pour les refuges. Des changements systémiques sont nécessaires pour mieux aider les intervenants de première ligne des hôpitaux et des refuges à améliorer le processus de sortie.
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Data availability
Not available due to participant privacy.
Notes
For results on how knowledge sharing and the involvement of shelter workers in discharge planning is shaped by legal, geographic, and organizational contexts, see Jenkinson et al. (2020).
References
Angus, J., & Clark, A. M. (2012). Using critical realism in nursing and health research: promise and challenges. Nursing Inquiry, 19(1), 1–3. https://doi.org/10.1111/j.1440-1800.2011.00580.x.
Aubry, T., Farrell, S., Hwang, S., & Calhoun, M. (2013). Identifying the patterns of emergency shelter stays of single individuals in Canadian cities of different sizes. Housing Studies, 28(6), 910–927. https://doi.org/10.1080/02673037.2013.773585.
Backer, T. E., Howard, E. A., & Moran, G. E. (2007). The role of effective discharge planning in preventing homelessness. The Journal of Primary Prevention, 28(3-4), 229–243. https://doi.org/10.1007/s10935-007-0095-7.
Blom, B., & Moren, S. (2011). Analysis of generative mechanisms. Journal of Critical Realism, 10(1), 60–79.
Buccieri, K., Oudshoorn, A., Frederick, T., Schiff, R., Abramovich, A., Gaetz, S., & Forchuk, C. (2018). Hospital discharge planning for Canadians experiencing homelessness. Housing, Care and Support. https://doi.org/10.1108/HCS-07-2018-0015.
Chamie, J. (2017). As cities grow worldwide, so do the numbers of homeless. Retrieved from: https://archive-yaleglobal.yale.edu/content/cities-grow-so-do-numbers-homeless. Accessed July 2019.
City of Toronto. (2018). Backgrounder: results of the 2018 street needs assessment. Retrieved from https://www.toronto.ca/home/media-room/backgrounders-other-resources/backgrounder-results-of-the-2018-street-needs-assessment/.
City of Toronto. (N.D.). Daily shelter and overnight service usage. Retrieved from https://www.toronto.ca/city-government/data-research-maps/research-reports/housing-and-homelessness-research-and-reports/shelter-census/.
Cornes, M., Whiteford, M., Manthorpe, J., Neale, J., Byng, R., Hewett, N., et al. (2018). Improving hospital discharge arrangements for people who are homeless: a realist synthesis of the intermediate care literature. Health & Social Care in the Community, 26(3), e345–e359. https://doi.org/10.1111/hsc.12474.
Craig, P., Di Ruggiero, E., Frohlich, K. L., Mykhalovskiy, E., & White, M. (2018). Taking account of context in population health intervention research: guidance for producers, users and funders of research. Southampton (UK): NIHR Journals Library. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK498645/. doi: https://doi.org/10.3310/CIHR-NIHR-01.
De Souza, D. E. (2013). Elaborating the context-mechanism-outcome configuration (CMOc) in realist evaluation: a critical realist perspective. Evaluation, 19(2), 141–154.
Doran, K. M., Ragins, K. T., Gross, C. P., & Zerger, S. (2013). Medical respite programs for homeless patients: a systematic review. Journal of Health Care for the Poor and Underserved, 24(2), 499–524. https://doi.org/10.1353/hpu.2013.0053.
Fletcher, A. (2017). Applying critical realism in qualitative research: methodology meets method. International Journal of Social Research Methodology, 20(2), 181–194.
Forchuk, C., Godin, M., Hoch, J. S., Kingston-Macclure, S., Jeng, M. S., Puddy, L., et al. (2013). Preventing homelessness after discharge from psychiatric wards: perspectives of consumers and staff. Journal of Psychosocial Nursing and Mental Health Services, 51(3), 24–31. https://doi.org/10.3928/02793695-20130130-02.
Frankish, C. J., Hwang, S. W., & Quantz, D. (2005). Homelessness and health in Canada: research lessons and priorities. Canadian Journal of Public Health, 96(Suppl 2), S23–S29 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16078553.
Gaetz, S. (2010). The struggle to end homelessness in Canada: how we created the crisis, and how we can end it. The Open Health Services and Policy Journal, 3, 21–26.
Gaetz, S., Dej, E., Richter, T., & Redman, M. (2016). The state of homelessness in Canada 2016. Retrieved from web: https://www.homelesshub.ca/SOHC2016.
Georgiadis, A., Corrigan, O., & Speed, E. (2017). Frontline healthcare staffs’ experience of organizing complex discharges: an ethnographic study. Ethics and Behavior, 27(4), 335–350. https://doi.org/10.1080/10508422.2016.1200977.
Hwang, S. W., Weaver, J., Aubry, T., & Hoch, J. S. (2011). Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Medical Care, 49(4), 350–354. https://doi.org/10.1097/MLR.0b013e318206c50d.
Hwang, S. W., Chambers, C., Chiu, S., Katic, M., Kiss, A., Redelmeier, D. A., & Levinson, W. (2013). A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance. American Journal of Public Health, 103(Suppl 2), S294–S301. https://doi.org/10.2105/AJPH.2013.301369.
Jenkinson, J. I. R., Strike, C., Hwang, S. W., & Di Ruggiero, E. (2020). Legal, geographic and organizational contexts that shape knowledge sharing in the hospital discharge process for people experiencing homelessness in Toronto, Canada. Health and Social Care in the Community. https://doi.org/10.1111/hsc.13206.
Kangovi, S., Mitra, N., Norton, L., Harte, R., Zhao, X., Carter, T., et al. (2018). Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: a randomized clinical trial. JAMA Internal Medicine, 178(12), 1635–1643. https://doi.org/10.1001/jamainternmed.2018.4630.
Lawson, T. (1997). Economics and reality. London: Routledge.
Lyon-Callo, V. (2000). Medicalizing homelessness: the production of self-blame and self-governing within homeless shelters. Medical Anthropology Quarterly, 14(3), 328–345. https://doi.org/10.1525/maq.2000.14.3.328.
Poland, B., Frohlich, K. L., & Cargo, M. (2008). Context as a fundamental dimension of health promotion program evaluation. In L. Potvin & D. V. McQueen (Eds.), Health promotion evaluation practice in the Americas: values and research (pp. 299–317). Springer.
Popay, J., Escorel, S., Hernández, M., Johnston, H., Mathieson, J., & L., R. (2008). Understanding and tackling social exclusion: final report to the WHO Commission on Social Determinants of Health from the Social Exclusion Knowledge Network. Retrieved from Geneva, Switzerland.
Pottie, K., Kendall, C. E., Aubry, T., Magwood, O., Andermann, A., Salvalaggio, G., et al. (2020). Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. CMAJ, 192(10), E240–E254. https://doi.org/10.1503/cmaj.190777.
Premier’s Council on Improving Healthcare and Ending Hallway Medicine. (January 2019). Hallway health care: a system under strain. Retrieved from Online: http://www.health.gov.on.ca/en/public/publications/premiers_council/docs/premiers_council_report.pdf.
Ruckert, A., & Labonte, R. (2014). The global financial crisis and health equity: early experiences from Canada. Globalization and Health, 10, 2. https://doi.org/10.1186/1744-8603-10-2.
Saab, D., Nisenbaum, R., Dhalla, I., & Hwang, S. W. (2016). Hospital readmissions in a community-based sample of homeless adults: a matched-cohort study. Journal of General Internal Medicine, 31(9), 1011–1018. https://doi.org/10.1007/s11606-016-3680-8.
Stuckler, D., Reeves, A., Loopstra, R., Karanikolos, M., & McKee, M. (2017). Austerity and health: the impact in the UK and Europe. European Journal of Public Health, 27(suppl_4), 18–21. https://doi.org/10.1093/eurpub/ckx167.
Whiteford, M., & Cornes, M. (2019). Situating and understanding hospital discharge arrangements for homeless people. Housing, Care and Support, 22(1), 1–3. https://doi.org/10.1108/HCS-03-2019-030.
Acknowledgements
We would like to thank our participants for their time and for sharing their stories. Additionally, we want to acknowledge the support of the site principal investigators who helped us recruit participants at each hospital.
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This work was supported in part by the Social Sciences and Humanities Research Council of Canada [752-2017-1416], and the University of Toronto Open Fellowship. The funders had no role in the design of the study and collection, analysis, and interpretation of data, or in writing the manuscript.
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Jesse Jenkinson: Conceptualization, methodology, investigation, resources, data curation, formal analysis, writing (original draft), and visualization. Stephen W. Hwang: Conceptualization, methodology, and writing (review and editing). Carol Strike: Conceptualization, methodology, and writing (review and editing). Erica Di Ruggiero: Supervision, conceptualization, methodology, and writing (review and editing).
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Jenkinson, J.I.R., Strike, C., Hwang, S.W. et al. Nowhere to go: exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto, Canada. Can J Public Health 112, 992–1001 (2021). https://doi.org/10.17269/s41997-021-00561-0
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DOI: https://doi.org/10.17269/s41997-021-00561-0