We worked with the Toronto Central Local Health Integration Network (TC-LHIN) to explore how well the palliative care system works for people experiencing homelessness. We found that there are significant gaps that prevent people from receiving palliative and end-of-life care.

Read the full report here.

For more information, please contact sru@smh.ca.

Findings for current palliative care providers

  • Build capacity so that all providers are able to address the needs, rights and health and social circumstances of people who are experiencing homelessness.
  • Take a harm reduction approach to palliative care. Abstinence-based approaches present one of the most significant barriers to access for people who are experiencing homelessness and require a palliative care bed. Harm reduction should be embedded in a palliative approach to care.

“What worked really well was when we had Perram House as the palliative care unit for downtown… They were very flexible and so I would continue to follow people… They were very accepting of drug use and alcohol dependency. The nurses would allow for that, to accommodate in any way they could. It was just a great environment. The patient felt very comfortable there. Perhaps other palliative care units if they want to step up and take that on… that would be helpful”

  • Follow the patient, for example:
    • Developing the capacity to provide care in a range of settings. Current mainstream services are designed to support housed populations via traditional ‘home care’ services. Inner City Health Associate’s PEACH program is an example of a mobile palliative care program that delivers care in settings such as shelters and on the street.
  • Meeting patients outside of health care environments, e.g. rooming houses, transitional spaces and drop-in centers.
  • Ensuring continuity of care by following patients between services (e.g. when a client moves from a shelter into a palliative care unit or hospice setting).

“Continuity of care across settings is an enabler to make sure this population gets what they need. Like one of the issues is that we do all this work in the community and then they get hospitalized…if someone doesn’t know, they can undo all the work that we’ve done…”

  • Adopt flexible admissions criteria. People who are homeless are often living with more than one difficult medical condition. As a result, they may be too sick to live on their own, but assessed as not quite appropriate for palliative care. Admission criteria and lengths of stay should be adapted to accommodate people with an unclear prognosis and/or nonlinear disease trajectories, which are quite common for this population.

 “As soon as someone couldn’t get up and get out of their room for the day, they weren’t appropriate for the shelter anymore…  And a lot of the time, patients do not want to go yet. They want to remain a bit independent. But they were kind of on that cusp.”

  • Engage with social service providers such as shelter workers in order to identify patients in need of palliative care and people with whom patients have trusted relationships.
  • Honour relationships. Continuity of relationships is an extremely important part of the palliative care process. Palliative care providers must work to ensure that patients can maintain ongoing relationships with trusted health care providers, frontline workers and community members across services and throughout the palliative care process.

“They have their own physicians there and we don’t have privileges there so we do not continue to follow them when they go into PCU…that relationship is lost and they have to start all over again. One guy kept calling me, thinking I was going to be able to adjust his medications. And I said ‘I cannot. I don’t have any control anymore over your medications’ and he was really upset.”

Findings for health care funders, system planners and policy-makers:

  • Provide resources for capacity building. Funding should be allocated for planning, training and evaluation to ensure that current palliative care providers have the capacity to meet the needs of people experiencing homelessness.
  • Address restrictive criteria system-wide. Policy-makers should:
    • Review criteria for admission to inpatient facilities such as:
      • Bans on substance use
      • Bans on patients with different kinds of ‘difficult behaviours’
      • Strict definitions of ‘palliative’
      • Timelines for length-of-stay
    • Add dedicated palliative care beds for people experiencing homelessness. While a small number of dedicated palliative care beds are coming online in downtown Toronto, they do not come close to meeting the need. A number of models of palliative care for people experiencing homelessness are suggested in the full report. Health care policy-makers, planners and funders should assess gaps that cannot be met by mainstream providers, and bring additional beds online in keeping with the need.