Many urban centres around the world are home to financially insecure people managing numerous clinical and psychosocial challenges, including substance abuse and mental health conditions. As a result, urban hospitals often become the care provider for underserved patients when no one else can step up. Ambulances and even police dispatches bring these patients to the emergency department when their conditions are at their worst, often because there's nowhere else to take them.
Seven lessons on developing a sustainable community partnership
For hospitals, the impact is pronounced. These patients' lengths of stay are longer as clinicians work to stabilise 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's capital city, a group of leaders came together in response to the outsized demand the homeless population was having on the city's health care system. Stakeholders from local homeless shelters, the health department, community care, and The Ottawa Hospital partnered to establish Ottawa Inner City Health (OICH), a nonprofit organisation that serves the homeless community.
Since its launch in 2001, OICH has grown from 30-bed pilot programme to 230-bed initiative that oversees several different programmes for Ottawa's homeless population, including primary care, palliative care, dental care, and mental health and substance abuse services. Logistically, 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 programme—supports OICH's day-to-day management.
One particularly successful programme is the ED diversion programme. 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.
And 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 presentations and hospital stays.
Achieving this success has required new relationships with partners that health care organisations are not traditionally used to working with, such as housing and police. The OICH team also recognises 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 under-served
Partnering effectively to care for the homeless population has required a major shift in mindset from one of the organisation's most prominent partners: the hospital.
Over the past 18 years, the most important lesson the OICH team learned is that 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 homeless population, this approach means going to homeless shelters rather than trying to recruit patients to the hospital for services—but this is far from the usual way of working.
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 being comfortable with 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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