Living & Dying on the Streets:Supporting the Palliative Care Needs of the Homeless & Vulnerably Housed

Naheed Dosani, MD, CCFP(PC), BScProject Lead & Palliative Care PhysicianPalliative Education And Care for the Homeless (PEACH)Inner City Health Associates, Toronto, Ontario

Gratitude

Conflicts Of Interest

None to declare

Agenda

1. Review the impact of the social determinants of health on health outcomes & palliative care delivery

2. Describe the unique challenges faced by homeless & vulnerably housed populations with life-limiting illnesses

3. Review promising interventions to address the Supportive & Palliative Care needs of the homeless & vulnerably housed

4. Review promising practices

What makes us sick?

Canadian Medical Association, 2015

Terry

Terry

Homelessness: A Definition

● Encompasses a wide-range of living situations● A continuum:

■ living outside or in places not fit for human habitation

■ staying in temporary or emergency accommodations (emergency shelters)

■ living in accommodations without security of tenure (couch-surfing, rooming houses)

Guirguis-Younger et al, 2014

Homelessness: A Definition

● living at risk of homelessness due to lack of financial security or other factors (IPV, separation, divorce) that may compromise housing

● Experienced differently, by different people; various factors:

■ individual ■ social ■ structural

Guirguis-Younger et al, 2014

Quantifying Canada’s Homeless

● A growing population○ “tens of thousands”

■ 35 000 people nightly■ 150 000 sheltered annually■ 150 000-300 000 homeless people per

year○ heterogeneous

Canadian Observatory on Homelessness, 2014Fazel et al, 2014

Quantifying our ‘Vulnerably Housed’

Hwang et al, 2011

The vulnerably housed

● >50% income = rent● poor conditions● instability, recent or episodic homelessness

Why differentiate?● The vulnerably housed are just as sick as the

homeless

Substance Use & Mental Health Among the Homeless

The health of the homeless

● 75% with one or more chronic disease○ HCV: 28x○ Heart Disease: 5x○ Cancer: 4x

● Presentation to acute care:○ ED: 8x○ Hospital admission: 4x

● Shifting demographics:○ >55 years old: 10% St Micheal’s Hospital, 2014

Podymow et al, 2006Cagle, 2009Plunkett, 2016

Homeless at end-of-life

● Highest all-cause mortality rate of any population in Canada○ Life expectancies: 34 - 47 years old○ Mortality rates: 2.3x - 4x

● Location at EOL:○ ED & acute hospital [vast majority]○ transitional spaces○ shelter-settings

St Micheal’s Hospital, 2014Podymow et al, 2006Cagle, 2009Plunkett, 2016

Megaphone Magazine, 2014

50%

Best Practices: Palliative Care

Best Practices: Homeless Health

● Outreach● Intensive case management● Interdisciplinary

○ Addictions○ Mental health

● Care across settings

A palliative approach to street health

A new model of care

PEACH: Program Specifics

● Funding: ○ Ministry of Health & Long-Term Care

● Partnership:○ Inner City Health Associates & Toronto Central CCAC○ Launched in July 2014

● Referral Process:○ low-threshold AND low-barrier○ social service organizations, housing/shelter agencies, health

providers○ strategic relationships (eg hospital discharge planners,

health/social services for the homeless)● Staffing Model:

○ 0.2 FTE: Palliative Care Consultant Physician○ 0.6 FTE: PEACH Coordinator○ Toronto Central CCAC Palliative Care Coordinator

Our beacons of hope!

PEACH: Program Specifics

● Program Size: ○ 50-70 patients on caseload at any time○ >150 patients since July 2014

● Eligibility Criteria:○ City of Toronto, meeting Canadian definition of homelessness○ NO life expectancy requirement○ Cancer Care Ontario: Early Identification & Prognostic Indicator Guide

● Care philosophy:○ ‘home-visit model’ seeing people in streets, transitional housing,

shelters, rooming & boarding houses etc.○ ‘home care for the homeless’ via Toronto Central CCAC interventions○ access to larger networks & organizational partners support

wrap-around service delivery

PEACH: Program Specifics

● Capacity building:○ not a takeover care model○ building a ‘compassionate community’ around each patient○ follow patient care across settings (eg community, ED, hospital,

PCU/hospice)○ Medical education: >75 medical students & post-graduate training

experiences via partnership with University of Toronto’s Department of Family & Community Medicine

○ Interdisciplinary education: >40 learning experiences for trainees from nursing, social work, research, dietetics and occupational & physical therapy backgrounds

● Case management:○ ‘Street navigation’ AND ‘Palliative Care’ navigation for effective

community-based care coordination○ Advocacy re: access to acute PCU, EOL PCU/hospice beds

PEACH: Looking at Outcomes

PEACH Internal 1-year Retrospective Audit, 2014-2015

PEACH: Looking at Outcomes

● No ED/acute hospitalizations: 64%● EOL in location of preference: 78.3%● Reconnected to family/friends: 82.6%● Opioids:

○ Prescribed: 58.5%○ Substance use risk assessments:

90.2%● Shared care: 82.9%

PEACH: Looking Ahead

● Expansion● The ‘Good Wishes’ project● Homeless Palliative Care guidelines● Hospice for the homeless

Other Emerging ‘Mobile’ Models

Calgary Allied Mobile Palliative Program (CAMPP)

Calgary, Alberta University of Calgary: Division of Palliative Care, Calgary Urban Project Society, Street CCRED, United Way of Calgary and Area

Mobile Palliative Care Program for the Homeless (MPCH)

Seattle, Washington University of Washington School of Public Health, University of Washington Medical Center, Harborview Medical Center

TBA Brisbane, Australia Mater Hospital & St Vincent’s Hospital

Other Emerging ‘EOL’ Models

The Diane Morrison Hospice Ottawa, Ontario Ottawa Mission Shelter, Ottawa Inner City Health, Champlain CCAC, Elizabeth Bruyere Health Centre

St Mungo’s Palliative Care Service London, UK St Mungo’s, Marie Curie Cancer Centre, Department of Health

Death is a social justice issue

‘Double’ Vulnerability

Reimer-Kirkham et al, 2016

McNeil, 2015

The elephant in the room?

Are we achieving palliative care equity?

Puri, 2016

SDoH & Palliative Care: The gap is real

● Palliative care patients living in the poorest neighbourhoods (still housed) in Ontario:○ were least likely to get a home visit from a

doctor (29.4% vs 40.2%)○ were more likely to have unplanned ED visits

(65.4% vs 59.8%)○ were more likely to get admitted to hospital

in their last 30 days of life (64.5% vs 58.9%)○ were more likely to die in hospital (68.5% vs

61.5%)

Health Quality Ontario, 2016

A key determinant of palliative care access

YOUR POSTAL CODE!

Correlations to access

● Education● Income● Social class

Campbell, 2010

Our accountability to a human right

“Everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” - UN Universal Declaration of Human Rights

Palliative care: our accountability

“An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual…”- WHO definition of ‘Palliative Care’, 2002

Structural vulnerability

“An individual’s or a population group’s condition of being at risk for negative health outcomes through their interface with socioeconomic, political, and cultural/normative hierarchies. Patients are structurally vulnerable when their location in their society’smultiple overlapping and mutually reinforcing power hierarchies (e.g., socioeconomic, racial, cultural) and institutional and policy-level statuses (e.g., immigration status, labor force participation) constrain their ability to access health care and pursue healthy lifestyles.”

- Bourgois et al, 2017

10 Promising Practices to improve Palliative Care delivery for the homeless &

vulnerably housed

1. Let’s not reinvent the wheel: integrate social & health services

2. The name of the game is coordination

3. Keep your eyes on the prize: Build community capacity

4. Provide palliative care where people are at

5. Adopt harm reduction approaches to care

6. Ensure flexibility in program policies

7. Training & education

8. Prioritize client dignity

9. Employ holistic care models

10. Foster peer supports: Include street and/or ‘chosen’ family in care

Lessons Learned

● The palliative trajectories of the homeless & vulnerably housed are uniquely complex

● There is a need to develop flexible, integrated & mobile care models to meet the complex physical & psychosocial needs of the homeless

● Early evidence suggests that emerging ‘mobile’ models meet patient needs AND reduce healthcare utilization

● Sustainable funding models are required to support emerging program models

Lessons Learned

● Emerging models derive greater success when integrated within larger healthcare systems, providing structure, technical and staffing supports, while framing the model in the context of a larger referral base

● Collaboration between Palliative Care providers and health/social providers working with the homeless is essential to build effective, holistic and flexible care models that can be tailored to different communities

● Unified definitions & criterion among service providers can allow for streamlining specific ‘pathways of care’, to optimize resources & best serve the homeless

Thank you!

References & Citations

Available upon request