image: Homeless Health Research Network
A collaborative approach is required to build healthcare pathways that will end homelessness in Canada, says the Homeless Health Research Network, a pan-Canadian team of experts including researchers from McGill University. Clinicians can play a role by tailoring their interventions using a comprehensive new clinical guideline on homelessness published in the Canadian Medical Association Journal.
The guidelines aim to inform clinicians and encourage collaboration with community organizations and policy-makers around priority steps and evidence-based interventions to treat homeless and precariously-housed people at risk of homelessness.
"It's important that clinicians get involved in ending homelessness because they are so well-placed to make a difference," says co-author Dr. Anne Andermann, an Associate Professor in the Department of Family Medicine and Director of Community-Oriented Primary Care at McGill. "As a first step, we can learn to adapt our clinical approach to better address patient needs in a more integrated way - including their physical health, mental health, and social challenges."
A network of clinicians, academics, and governmental and nongovernmental stakeholders called the Homeless Health Research Network, as well as five people with lived experience of homelessness, created the guideline. Among the co-authors of the guidelines are also two McGill medical students Sebastian Mott and Victoire Kpadé. A steering committee with representatives from across Canada helped coordinate the process.
"Housing is medicine," says Amanda DiFalco, fellow at the Institute of Global Homelessness, and who has experienced homelessness. "We need to integrate these guidelines into health policy and how we teach the next generation of clinicians."
The guideline, which will be updated every five years, recommends the following interventions to help patients who are homeless or vulnerably housed:
1. Permanent supportive housing: connect homeless or vulnerably housed people to a local housing coordinator or case manager to provide links to housing options
2. Income assistance: help people with income insecurity to find and access income-support resources
3. Case management: ensure people with mental health and substance use disorders access local mental health programs and psychiatric services
4. Opioid agonist therapy: provide access to opioid agonist therapy in primary care or referral to an addiction specialist for patients with chronic opioid use
5. Harm-reduction: identify appropriate management for people with substance use issues, or refer them to local addiction and harm reduction services
The homeless population is changing
The homeless population in Canada has changed considerably over the last 25 years, from mostly middle-aged men to increasing numbers of women, youth, Indigenous people, older adults and even families. The estimated homeless population in 2014 was 235,000, of whom 27.3% were women, 18.7% were youth, 6% were recent immigrants or migrants, and a growing number were veterans or seniors.
"Over 2 million Canadians have experienced hidden homelessness in their lifetime, meaning that they have used 'couch surfing' or other approaches to avoid staying in shelters or living on the street," says Dr. Andermann, who founded a community outreach clinic with St. Mary's Family Medicine Centre and the Multicaf food bank in Côte-des-Neiges.
Indigenous homelessness
In Canada, Indigenous peoples are eight times more likely to be homeless than non-Indigenous people. However, there are few Indigenous-led approaches to address homelessness.
To fill this gap, Indigenous historian and York University professor Jesse Thistle and Dr. Janet Smylie, a Métis family physician and research chair at Unity Health Toronto and the University of Toronto, are leading the development of a separate guideline to address Indigenous homelessness. Indigenous elders, researchers and scholars as well as people with experiences of homelessness helped develop the guideline.
While standard definitions of homelessness focus on housing precarity, the researchers based their guideline on a definition of Indigenous homelessness rooted in a breakdown of healthy relationships resulting from colonial disruptions. They propose four broad protocols for health and social service providers working with Indigenous peoples experiencing homelessness: situating one's self, keeoukaywin (visiting), hospitality, and treating people as you would treat your own relative.