This executive summary lays out highlights from the report Promoting Continuity of Care for People Experiencing Homelessness and Alcohol Addiction, written by Max Bell School Master of Public Policy students as part of the 2022 Policy Lab.
Access the summary and presentation below, and read their full report here.
People experiencing homelessness and alcohol addiction are likely to present with a complex health profile, including a range of physical, mental, social, and substance use needs. To respond to these complex needs, tailored and holistic health care is required. In June 2022, the Old Brewery Mission (OBM), a homeless-serving shelter in Montréal, launched a managed alcohol program which adopts a harm reduction approach to alcohol addiction. This program provides measured doses of alcohol to help participants manage their addiction, in place of the traditional abstinence-based approach. In addition, participants receive wrap-around services to help meet psycho-social needs, recognizing that treatment for alcohol addiction is just one aspect of their broader needs. Given the intensity of support provided by the managed alcohol program, this report aims to explore the challenges and barriers within the Montréal health care system that inhibit adequate and holistic health care provision prior to individuals seeking out intensive health care support through a managed alcohol program.
People experiencing homelessness and alcohol addiction face particular barriers with respect to accessing health care provided by the public health system, arising from the system being ill-adapted to their needs and realities. These barriers exist in primary care, specialized care, and interactions with health human resources, resulting in an overall health care experience characterized by a lack of continuity of care. People experiencing homelessness and alcohol addiction are provided little targeted support in navigating the health care system, nor are they typically prioritized for health care services.
This report presents key challenges and barriers experienced by the target population as they navigate the health care system. Key findings are summarized below.
Primary care: Although the overall population in Québec is often unable to access primary care, especially with respect to family physicians, people experiencing homelessness face a particular set of additional barriers that limit their access to primary care. Some of these barriers arise from the circumstances of experiencing homelessness, while others are systemic challenges. For one, basic needs such as obtaining shelter and food may take priority over health care needs. In addition, people experiencing homelessness may not have the necessary resources to seek out, access, and follow-up with primary care, including consistent access to phone lines, internet, or transportation options. Broader systemic barriers include the fee-for-service remuneration structure for family physicians, which incentivizes abbreviated visits and does not lend itself to patients with complex needs. Moreover, frequent loss and theft of health cards pose an ongoing challenge, despite policy accommodations to facilitate renewal of health cards. These challenges limit access to primary care, which means people experiencing homelessness often do not have established contact with the health care system. As a result, continuity of care is impeded for their overall health care needs, including the need for more specialized care.
Specialized care: The nature of the specialized care system, which is designed to address specific needs often in isolation from an individual’s broader health profile, presents a barrier to receiving care in a holistic manner for people experiencing homelessness. This challenge, inherent to the design of the system, is further compounded as people experiencing homelessness typically present with complex health profiles, but experience difficulties in attending multiple appointments for specialized services. Moreover, organizational policies and practices that do not account for the accessibility needs of people experiencing homelessness pose additional barriers. These challenges and barriers prevent people experiencing homelessness from having their specialized needs addressed, and contribute to the lack of continuity of care experienced within the health care system.
Interactions with health human resources: Throughout their interactions with health care providers and front-line staff, people experiencing homelessness often experience stigmatization and other harmful attitudes. This is often a consequence of staff being overburdened and undertrained to support people experiencing homelessness in a sensitive, trauma-informed manner. These interactions discourage people experiencing homelessness from seeking health care, and by extension, negatively impact the formation of stable, trusting relationships with health care providers.
These issues compound to create an over-reliance on emergency departments, which are unsuited to addressing the complex needs of the target population given the episodic nature of emergency care. These challenges reflect a health care system that is not well-equipped to provide holistic, coordinated health care services that are accessible and adapted to the complex health care needs of this population. This results in an overall health care experience where continuity of care is severely limited.
Recommendations
To improve continuity of care for people experiencing homelessness and alcohol addiction, five recommendations have been designed for OBM and the public health care system. The objective of the recommendations is to help OBM and the health system better respond to the needs of this population. With respect to the public health care system in particular, the recommendations are intended to go a step further in adapting service provision to the unique realities of homelessness. These recommendations acknowledge that people experiencing homelessness and alcohol addiction often present with a complex health profile overall, of which alcohol addiction is one component, and are designed from the perspective of improving access to, and better continuity of care.
The recommendations are:
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Incorporation of Health System Navigators at OBM and Within the Broader Public Health System: OBM should create a health system navigator role to assist clients with understanding and navigating the health care system. OBM should likewise advocate for the same navigator function within public hospitals in the health care system, to ensure the target population is connected with health care services and experiences continuity of care among health care services. Similar to other shelters in Canada, OBM should also create a peer support network of current or former OBM clients to assist navigators with specific tasks, such as the coordination of transport for clients to attend health-related appointments.
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Implementation of a Pilot Integrated Community Clinic Targeted for People Experiencing Homelessness: OBM should advocate for, and work with the public health care system to, pilot a community clinic that offers primary health care, and potentially some specialized health care services, for people experiencing homelessness in downtown Montréal. This clinic would be an integrated and innovative solution that addresses major barriers to access, and lack of continuity of care, for people experiencing homelessness. A partnership would allow the public health care system, homeless-serving shelters, and other non-profit organizations to work together to meet the unique needs of this population.
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Training of Health Human Resources on Trauma-Informed Care: OBM should offer appropriate training on trauma-informed, person-centred care for all staff, and advocate for this training to be offered in the public health care system. Trauma-informed care has been demonstrated to be effective in improving patient safety and trust, and person-centred care likewise improves interactions through greater openness and conflict resolution. These skills are essential for the health care workforce to adopt to improve trust and build positive relationships with people experiencing homelessness.
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Greater Availability of Low-Threshold Services: OBM should advocate for amending policies and rules within addiction and specialized services that present particularly high thresholds to access for people experiencing homelessness. These include, for example, sobriety requirements, as well as more general policies, such as limited hours of access or restrictions on mobility, that prevent the target population from using specialized services. Adopting a low-threshold model would instead make minimal demands on patients, recognizing that services should be better adapted to increase acceptability and access for people experiencing homelessness.
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Review the Wider Policy Settings Affecting the Health System: Within the health care system, there are various policies at the operational and institutional level that create undue barriers for the target population. OBM should advocate for, and participate in, a review of policies that present complex and significant challenges for people experiencing homelessness in their interface with the health care system:
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Institutions and points of access to the system: examine location and physical accessibility of services;
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Regulatory options: examine policies that impose conditions and requirements for accessing services, particularly with respect to RAMQ cards and information-sharing between public and private health providers (e.g. shelters); and
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Funding and incentives: explore options to improve capacity and incentives for family physicians to take on people experiencing homelessness within their roster of patients, and increase wages and benefits for health care staff to improve their ability to support people experiencing homelessness.
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Taken together or individually, these recommendations serve as concrete opportunities to make health care system-level interventions to help adapt the system to better respond to the needs of people experiencing homelessness, and as a result, improve continuity of care for this population. An implementation plan, provided in Appendix B, suggests concrete activities to implement each recommendation, along with proposed timelines. However, OBM may wish to adapt this approach according to its own assessment of the priority and the capacity of partner organizations to engage. Further engagement, particularly with people with lived experience of homelessness and alcohol addiction, should inform the approach to, and implementation of, the recommendations.
Download the full version of this report here.
This Policy Lab was presented by our MPPs on July 11, 2022. Watch the video below:
About the authors:
Akriti
MPP Class of 2022
Daniel Cruden
MPP Class of 2022
Kerry Kittson
MPP Class of 2022
Tooba Malik
MPP Class of 2022
Juma Omala
MPP Class of 2022
