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Offering housing services? You may require a major mind shift

September 18, 2019

    Editor's note: This is part of a series about care transformation around the globe, where we look at successful population health managers outside the United States. A version of this post previously ran on the The Forum blog.

    Patients experiencing homelessness are more likely to struggle with physical trauma, unmanaged chronic conditions, and behavioral health emergencies. They are also less likely to access adequate care. These factors can reduce a patient's life expectancy by up to 36 years. When patients experiencing homelessness are in crisis, safety-net organizations are tasked with meeting their complex needs. 

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    For hospitals, the cost impact is pronounced. These patients' lengths of stay are longer as clinicians work to stabilize multiple conditions—including mental health and social challenges that providers aren't always equipped to address.

    Building a comprehensive approach to homelessness

    In Ottawa, Canada, a group of leaders came together in response to the outsized health needs of community members experiencing homelessness. Stakeholders from local homeless shelters, the health department, community care, and The Ottawa Hospital partnered to establish Ottawa Inner City Health (OICH), a nonprofit organization that meets the needs of people experiencing homelessness.

    Since its launch in 2001, OICH has grown from a 30-bed pilot program to a 230-bed initiative that oversees several different programs, including primary care, palliative care, dental care, mental health care, and substance use services. Ontario's government provides funding for health care-related costs, and The Ottawa Hospital—which played a key role in ensuring stable funding for the program—supports OICH's day-to-day management.

    One particularly successful program is the ED diversion program. Patients who normally would have been brought to the ED by police or paramedics are now brought directly to homeless shelters that are outfitted to provide scaled-up support through OICH.

    The results are impressive: OICH successfully diverts 3,400 ambulance visits every year, which saves $1.3 million annually in health care costs from avoided ED use and hospital stays.

    Achieving this success required new partnerships that health care organizations are not traditionally experienced in, such as housing agencies and police departments. The OICH team also recognizes that improving health outcomes for the homeless and other vulnerable populations involves not only providing better health care, but also addressing housing, poverty, and other underlying social determinants of health. To that end, OICH is working to create networks of integrated care, aided by the Ontario government's new health care reform to promote integrated team models

    New partnerships and mindsets required to reach the underserved

    Partnering effectively to care for community members experiencing homelessness has required a major shift in mindset for The Ottawa Hospital.

    Over the past 18 years, the most important lesson the OICH team learned is that in order to improve care quality and access for an underserved and vulnerable population, care must be delivered where and when it's most readily accessible to patients. For Ottawa's population experiencing homelessness, this approach means going to shelters rather than trying to recruit patients to the hospital for services.

    Traditionally, the hospital is considered the hub of the health care system and best place for complex services. That mindset is beginning to change, but many hospitals still see themselves that way. However, OICH's success hinged on the hospital shifting service delivery to the community. The Ottawa Hospital has stepped up to the plate in this regard, and OICH co-founder Dr. Jeffrey Turnbull says that the hospital "is supportive of partners administering basic hospital services elsewhere," largely because it sees that this new approach benefits both patients and providers.

    Thinking about how to improve care for an underserved population in your area? Consider where and when this population needs care, how this approach may change the usual way of working, and how you can get the necessary partners on board with these changes.

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