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Patients benefit from providing health care alongside housing and other social supports
UHN identified 100 patients with no fixed address who visited the emergency department 4,309 times in a one-year period. (Pexels photo)
In Toronto’s Parkdale neighbourhood, an unlikely housing investor recently cut the ribbon on a new 51-unit building. The supportive housing apartments within promise to not only transform the lives of those who will soon occupy them but also the way we think about and deliver social programs.
Canada faces crises in health care, housing, homelessness, and mental health and addictions. We treat these issues distinctly despite extensive research demonstrating the links between health outcomes and social determinants such as income and access to housing.
Recognizing the critical role played by social determinants has led an Ontario hospital to enter the housing business. The University Health Network (UHN), in partnership with the United Way of Greater Toronto and the City of Toronto, is practising what Dr. Andrew Boozary of UHN calls “social medicine.”
Extending the traditional boundaries of health care is coming out of necessity. Hospitals nationwide face a crisis of demand, constrained budgets and staffing challenges. Many, like UHN, see people struggling with homelessness and mental health and addictions repeatedly turning up in emergency departments due to a lack of housing, income security and community supports.
UHN identified 100 patients with no fixed address who visited the emergency department 4,309 times in a one-year period. This data, along with the knowledge it’s cheaper and far better for the health of these patients to provide them with supports and shelter, prompted construction of the supportive housing units.
Improved access to housing through approaches that provide wrap-around supports has been shown to reduce substance use, police interactions, visits to emergency departments and hospital stays. For example, every $1 invested in Canada’s federally funded At Home/Chez Soi “housing first” program generated more than $2 in savings for the 10 per cent of participants with the highest health and social costs.
A glimpse of what is possible
UHN’s supportive housing initiative gives us a glimpse of what could be possible if we were to integrate housing or income security into an expanded concept of health care. This model would shift investments to program areas that shape the health of individuals and communities — investing in prevention rather than cure.
Our current system limits our ability to respond to interdependent issues affecting people’s lives. There are separate ministries (duplicated at various levels of government) for health, housing, community services and corrections, which pits departments against each other for funding. As a result, we spend far more on symptoms than the root causes of social issues to the detriment of people’s lives and government budgets.
There are many ongoing initiatives in Canada and elsewhere that seek to overcome this fragmentation that leads to duplication and reactive policymaking. Integration efforts in health care are often focused on better co-ordination between care providers to improve patient experience and outcomes.
Creating one pocket
Attempts to integrate sectors, such as housing and health care, are rarer and face the challenge of bridging enormous bureaucracies across multiple levels of government and service delivery providers. These political and social structures often work in isolation of each other, creating silos that prevent effective co-ordination and efficient use of resources.
A key to understanding the challenge of integration is found in what researchers call the “wrong pocket problem,” that is, when the department making an initial investment does not benefit from the savings generated. This helps explain why our social programs are so reactive and why programs demonstrating a positive return on investment — like At Home/Chez Soi — aren’t made permanent.
For example, if a housing ministry invests in affordable housing, it doesn’t realize the health savings generated. Those are captured elsewhere by different departments. This poor co-ordination results in a lack of incentive across governments to prioritize investments in housing, income security and other areas that prevent poor health outcomes, despite their potential for savings.
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UHN is motivated to invest in housing not only because it helps improve the well-being of patients, but because it is confident that the organization will directly benefit from reduced demand for health services. Putting health and housing under a single budget and provider ensures that any savings end up in the right pocket.
Some governments directly address the wrong pocket problem by pooling budgets. Norrtälje, a municipality of about 65,000 people north of Stockholm, Sweden, has integrated hospitals, primary care, long-term care, home care and other services under a single provider and budget. This merging motivates administrators to invest limited funds where they have the most impact. In Norrtälje, it has helped create a continuum of care with improved patient experience and outcomes.
Denmark, despite having an aging population like Canada, has managed to reduce demand for long-term care by substantially shifting investments to home care services. This approach respects the desire of seniors to remain in their homes as long as possible, but was also driven by the bottom line and a pooled budget. Municipalities in Denmark have responsibility for both home care and long-term care. Given that home-care costs are markedly less, Danish municipalities have a strong fiscal incentive to invest in programs that allow people to age safely at home.
In Canada, hospitals may be uniquely positioned to overcome the wrong pocket problem inherent in the integration of health and housing. Unlike provinces and larger municipalities, hospitals serve a more manageable population size. Perhaps most critically, hospitals have access to patient data to match housing supports to those in greatest need. This maximizes the return on investment and avoids privacy concerns.
There are many challenges to overcome in integrating housing and health. They include persuading various levels of government to shift funding and oversight to hospitals as well as navigating the relationships between hospitals and community agencies. But there is a common goal and obvious need.
The University Health Network’s new building will house a fraction of the more than 10,000 people currently experiencing homelessness in Toronto. But it is a step toward the transformative change and social medicine Canada needs to confront the country’s health care, housing, homelessness and mental health and addictions crises.
This article first appeared on Policy Options and is republished here under a Creative Commons license.
