Living & Dying on the Streets:

Transcription

1 Living & Dying on the Streets: Supporting the Palliative Care Needs of the Homeless & Vulnerably Housed Naheed Dosani, MD, CCFP(PC), BSc Project Lead & Palliative Care Physician Palliative Education And Care for the Homeless (PEACH) Inner City Health Associates, Toronto, Ontario

2 Gratitude

3 Conflicts Of Interest None to declare

4 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

5 What makes us sick? Canadian Medical Association, 2015

6 Terry

7 Terry

8 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

9 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

10

11 Quantifying Canada s Homeless A growing population tens of thousands people nightly sheltered annually homeless people per year heterogeneous Canadian Observatory on Homelessness, 2014 Fazel et al, 2014

12 Quantifying our Vulnerably Housed Hwang et al, 2011

13 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

14 Substance Use & Mental Health Among the Homeless

15 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, 2006 Cagle, 2009 Plunkett, 2016

16 Homeless at end-of-life Highest all-cause mortality rate of any population in Canada Life expectancies: years old Mortality rates: 2.3x - 4x Location at EOL: ED & acute hospital [vast majority] transitional spaces shelter-settings St Micheal s Hospital, 2014 Podymow et al, 2006 Cagle, 2009 Plunkett, 2016

17 Megaphone Magazine, 2014

18 50%

19 Best Practices: Palliative Care

20 Best Practices: Homeless Health Outreach Intensive case management Interdisciplinary Addictions Mental health Care across settings

21 A palliative approach to street health

22 A new model of care

23 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

24 Our beacons of hope!

25 PEACH: Program Specifics Program Size: 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

26 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

27 PEACH: Looking at Outcomes PEACH Internal 1-year Retrospective Audit,

28 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%

29 PEACH: Looking Ahead Expansion The Good Wishes project Homeless Palliative Care guidelines Hospice for the homeless

30 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

31 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

32

33 Death is a social justice issue Double Vulnerability Reimer-Kirkham et al, 2016

34 McNeil, 2015

35

36

37 The elephant in the room?

38

39 Are we achieving palliative care equity? Puri, 2016

40 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

41 A key determinant of palliative care access YOUR POSTAL CODE!

42 Correlations to access Education Income Social class Campbell, 2010

43 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

44 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

45 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 s multiple 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

46 10 Promising Practices to improve Palliative Care delivery for the homeless & vulnerably housed

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

48 2. The name of the game is coordination

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

50 4. Provide palliative care where people are at

51 5. Adopt harm reduction approaches to care

52 6. Ensure flexibility in program policies

53 7. Training & education

54 8. Prioritize client dignity

55 9. Employ holistic care models

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

57

58

59 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

60 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

61 Thank you!

62 References & Citations Available upon request