Homeless People Seek Shelter in Canada’s Strained EDs

Across Canada, people experiencing homelessness are seeking shelter in emergency departments (EDs) during cold snaps, especially if they suffer from negative health outcomes as the temperatures drop and snowstorms compromise their typical shelter areas.

Emergency clinicians may face a dilemma when they care for patients seeking shelter. In some cases, patients may have a health issue that needs care, but in other cases, they may simply need a warm place to stay. In most provinces, though, resources are scarce — both in strained EDs and at packed community organizations.

Since the pandemic began, EDs across Quebec, particularly in Montreal, have seen increasing volumes and fewer resources, Greg Clark, MD, an emergency physician at McGill University Health Centre, assistant professor of emergency medicine at McGill University in Montreal, Quebec, Canada, and a member of the administrative council of the Quebec Association of Emergency Physicians, told Medscape Medical News.

Several hospitals, for instance, have had occupancy rates above 200%, regardless of the time of year, he said. These rates become further exacerbated by severe cold and flu seasons, inclement weather, and an influx of patients experiencing homelessness.

“This isn’t a new phenomenon,” Clark said. “We’ve seen it for many years, especially in our urban area, but it can add on top of the other strains we’re seeing in EDs.”

A Complex Situation

Patients experiencing homelessness should be treated like any other patients, Clark said, noting that clinicians should ask about their medical complaints, perform an evaluation, and determine whether they need to remain in the ED for treatment.

After that, the next steps can “become grayer,” he said. “After assessing for the medical aspect, the social aspect becomes nebulous. Many of us weren’t trained to address these situations.”

EDs often serve as a last resort for various reasons, Clark said. In cases of homelessness, clinicians may be able to offer a connection to community resources, whether in the form of a warming center for shelter, drug counseling and harm reduction options, or mental healthcare facilities.

Many communities may not have these resources, however, or may lack space for new participants. In addition, patients experiencing homelessness may not want what’s offered, Clark said. They may have been ostracized or become victims of discrimination at medical or community facilities in the past and not know where to turn next.

“It’s frustrating, and this is a difficult problem to address,” he said. “In the ED, we have to be ready for everything, and that often means acting as a buffer for the gaps in our healthcare and social systems.”

Lacking Patient Resources

In Alberta, where the homeless population is growing faster than anywhere else in Canada, emergency physicians feel the dual strain of increased patient numbers and limited healthcare resources.

“We say a stagnant budget is, in reality, a budget cut, which is reflected in our lack of ability to care for our patients and in longer wait times,” said Warren Thirsk, MD, an emergency physician at Royal Alexandra Hospital, associate clinical professor of emergency medicine at the University of Alberta, Edmonton, Alberta, Canada, and president of the emergency medicine section of the Alberta Medical Association.

“The ED is there to serve the needs of all people,” he said. “We can’t turn off the patient inflow or determine for others what their emergency is — which can be the need for warmth, shelter, and safety.”

In the short term, Thirsk said, clinicians can assess their homeless patients for medical problems and then connect them with community resources, whenever possible. In Edmonton, though, many social, emotional, and financial needs appear to be going unmet.

“As a society, we need to set our priorities and make our funding match those priorities,” he said. “Unfortunately, the funding for healthcare in my province is in the hands of politicians, who aren’t aligned with those of us providing healthcare. To them, a budget line is meant to be cut.”

For long-term change in addressing homeless patients and ED capacity, more funding and new policies are urgently needed, he noted.

“The fascinating phenomenon with EDs is that no one thinks they need one until they need it, and then as soon as they need it, they need it immediately,” Thirsk said. “With resourcing and funding, we often live in the belief that it’s someone else’s problem until it’s our problem.”

Addressing Patient Needs

Clinicians can help people experiencing homelessness by adopting a trauma-informed approach to care, recognizing when homelessness or unstable housing contributes to ED and physician visits, and facilitating access to services that address the social determinants of health, according to a 2022 position statement by the Canadian Association of Emergency Physicians (CAEP).

“This is not a one-city issue. We see it across the country, and meeting people’s needs has become an increasing challenge for different reasons, such as capacity at emergency shelters, violence, and other issues that may lead to an untenable shelter space,” said Sahil Gupta, MD, co-author of the position statement, chair of CAEP’s Health Equity Committee, and an emergency physician at St. Michael’s Hospital in Toronto, Ontario, Canada.

“EDs have been safe havens for people for decades, but the volume and frequency are more challenging today,” he said. “More people are concerned about this issue because we know we don’t have enough shelter space for everybody.”

St. Michael’s Hospital, which reports more than 4000 homeless visits each year, has an outreach program to improve care for patients without housing. The program includes an intensive case management process to address social needs, such as obtaining identification, medication, and permanent housing.

“If you don’t have an ID or income support, you can’t even begin to think about exiting the cycle of homelessness,” said Gupta. “And to qualify for income support or get medications, you need an ID, so it can be a revolving door issue.”

The outreach program, which was launched in 2021, has assisted 100 people per year with social services and placed about 20 people into permanent residence each year.

“It may seem small, but it’s a big deal when someone has been houseless for years,” Gupta said. “If we’re able to help one person become housed, then the need for acute care services and hospitalizations improves significantly, and there are such dramatic differences in their life trajectory.”

Trying to address this complex issue at the individual provider or hospital level feels impossible, he said, but it’s fulfilling to take small steps as a team.

“This is a systems issue. With our program, we’re trying to connect the dots for people,” Gupta said. “But ultimately, we need a coordinated response and multiple layers of governance to come together to solve the issue.”

Clark, Thirsk, and Gupta reported having no relevant financial relationships.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.