In this issue of CMAJ, Alston and colleagues describe the urgent and complex problem of homelessness among older adults,1 a growing population nationwide.2 The latest report from the Canadian Institute for Health Information (CIHI) revealed that, in 2023, 30 000 people experiencing homelessness were admitted to hospitals in Canada, and these admissions lasted twice as long and were more than double the cost than admissions for people who were not unhoused.3 Both the CMAJ analysis and the CIHI report illuminate distressing compounding health effects of being unhoused, whereby people are sicker at hospital admission because they are unhoused and, when discharged, are not able to receive the primary care and home care services they require.4,5 Faced with the rising numbers of people experiencing homelessness, who often require extended hospital-based care, and in the absence of alternative solutions, some hospitals are building housing. Is this the most appropriate response, given the current demand for outstripped hospital resources?
The human toll of homelessness is immense. People who are chronically unhoused live half as long as those who are housed, experience accelerated aging, have many more comorbidities, and develop health conditions at a much younger age than those who are housed.5 Homelessness disproportionately affects Indigenous, Black, refugee and newcomer, and 2SLGBTQ+ people.6 Clinicians working in hospitals recognize the urgency of the problem, in part because emergency department visits by unhoused people have “skyrocketed” in recent years,7 and they have high rates of hospital admission.8
The rapid growth of unhoused populations in Canada is a consequence of policy decisions. In 1974, more than one-fifth of all housing options were social housing or nonmarket homes, which helped ensure affordability for people living with low incomes.9 Now, however, social housing is less than 4% of the total housing supply, and rents are soaring across the country.10 The decline in affordable housing greatly affects older adults, who often have fixed low incomes. A lack of affordable housing and appropriate community supports to help people age in place leaves older adults more vulnerable to becoming unhoused, with consequences for the health care sector. This problem has led several health networks to identify and implement upstream solutions.
First, hospitals can advocate alongside social service organizations that have expertise in housing to highlight the importance of affordable housing to policy-makers. Better integration of health and social support interventions can also help support patients experiencing homelessness when in hospital and upon discharge.11
A more unconventional approach is for hospital networks to leverage public land or other potential resources to build supportive housing in partnership with various levels of governments and social service organizations. In 2009, St. Joseph’s Health Centre created a housing corporation to increase broader access to affordable housing in Guelph, Ontario. It received funding from the federal and provincial levels to build an 80-unit rental housing development for low-income seniors.12 In Edmonton, the Bridge Healing Transition Accommodation launched in 2023, in partnership with Alberta Health Services, and provides 36 transition beds for patients discharged from emergency departments.13 In Toronto, the University Health Network (UHN) identified 51 patients with no fixed address who visited the emergency department more than 3300 times in 2023.13 These data compelled UHN to build 51 permanent Social Medicine Housing units on a parking lot for these high users of acute care services, in partnership with the City of Toronto and a nonprofit housing operator.
The fact that hospitals are dedicating scarce resources to provide housing is a testament to how undeniable the homelessness crisis has become and how ineffective and costly conventional approaches, such as lengthy hospital admissions, have been.
With the spring 2024 budget, Canada’s federal government endeavoured to remedy the decline in affordable housing through several policy levers; its focus on surplus, underused, and vacant public lands on which to build is particularly relevant to health care organizations.14 Through various funding streams, such as the $4 billion Rapid Housing Initiative, construction of affordable and supportive housing initiatives for people experiencing homelessness is emphasized and may enable funding for health care organizations to foster meaningful partnerships to expand housing access for those who need it most.
Under ideal conditions, hospitals and other health care institutions would not need to build supportive housing; realistically, the health sector will not be able to create enough affordable housing to extinguish the housing crisis. But the health care system and hospitals can help in concrete ways. The neglect of homelessness as a public health crisis is not sustainable, and Canadian society’s inaction has proven far too costly.
Footnotes
Competing interests: Andrew Boozary serves on the board of Inner City Health Associates. Competing interests for Catherine Varner and Andreas Laupacis can be found at www.cmaj.ca/staff.
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