Social Policy in Ontario

MONTREAL—In a group of several dozen homeless-health specialists from across the country that gathered last week in the basement of a Montreal hospital, two people stood out from the rest.

The medical professionals had stepped away from their street practices to begin drafting Canada’s first set of evidence-based guidelines on homeless health treatment — recommendations that have been tried and were proved successful.

The goal of the process is to ensure that doctors across the country are delivering quality treatment for people on the streets or close to it.

The air was thick with medical lingo. They spoke of “interventions” and “case management” and “shared-care models” and “patient-important outcomes.”

But during a morning break, Terry Hannigan and Christine Lalonde snuck outside for a cigarette and spoke about the gaps between what they heard in the conference room and what they had lived through when they were homeless.

Even among this well-meaning group of doctors and nurses — most of whom describe themselves as activists — the perceived solutions didn’t always square with the bleak realities of those on the street.

“They’re assuming that everyone who’s homeless has a primary physician,” said Lalonde, who lived in women’s shelters in Ottawa until securing housing in 2015. “I don’t have one.”

Hannigan, who was living in Toronto’s Maxwell Meighen Centre, Salvation Army shelter on Sherbourne St. until earlier this year, said he spent four months on the streets before he found a doctor willing to take him on as a patient. It was another two months before he got an appointment.

“I had to be very patient for it. In the interim I was in the shelter and didn’t have any medical care,” said Hannigan, who has participated in and directs courses at a mental-health recovery program run out of Toronto’s St. Michael’s Hospital.

Back inside the conference room, they both challenged the health experts, though Hannigan worried about being seen as a thorn in the side of the doctors and nurses in the room.

In fact, he is fulfilling the role he and Lalonde were recruited for by holding the proposed treatment guidelines up against their own experiences on the streets.

The result should assist doctors when they encounter, for example, a patient with a minor infection that is complicated by a mental-health disorder, drug addiction and an unstable income.

“Right now people question can we do anything or is this just social work? Can you really make an impact as a doctor?” said Dr. Kevin Pottie, an Ottawa physician and researcher who is leading the process of drafting the guidelines. “We want to say, yes, we have evidence that you can make an impact and these are the things you’re going to do.”

The process is partially funded by a $200,000 grant from Inter City Health Associates, a group Toronto doctors who work out of shelters and drop-in centres across the city.

Pottie brings an expertise in the rigorous methods for drafting guidelines and a background working with disadvantaged communities, including immigrants and refugees.

He hopes to come up with six or eight solid recommendations within the next year that will act as a sort of checklist for physicians who comes across a patient who is on the streets or in a precarious housing situation.

“We want them to be the most important and successful things for homeless people,” Pottie said.

Earlier this year, Pottie’s group conducted surveys to focus their work on the priority issues, including mental health and addiction treatment, co-ordination of care and access to income.

But the most important issue for the 84 health-care workers and homeless advocates as well as the 76 people who are or have been homeless was housing, perhaps not surprisingly.

This dovetails with a recent shift in thinking about how to treat the ailments that frequently accompany cases of homelessness, said Tim Aubry, a psychology professor at the University of Ottawa.

“We’ve finally come around to this idea that, if they’re homeless, maybe the first thing you should do is get them in a home rather than say they need more life skills, or to get their symptoms down, or they’ve got to stop using (drugs),” he said.

“If you think about it, if somebody’s homeless and you’re trying to fix everything else but the housing it doesn’t make sense.”

The guidelines could recommend that doctors refer homeless patients to programs that provide housing vouchers or accommodation that is not contingent on them staying clean and sober so that they can focus on recovering without worrying about where they’ll sleep at night.

One group of doctors broke away to discuss the benefits of income supplements — another acknowledgement of the non-medical factors at play in the homeless-health equation.

“There’s probably about five or six people that are informing my comments in terms of what’s relevant,” said Dr. David Tu, a family physician at the Vancouver Native Health Clinic. “We’re talking about income right now. Being able to find employment opportunities would have made a world of difference.”

Or as Lalonde noted earlier in the day: “I don’t care about a fungus on my toe when I have nowhere to live. I’m not going to go out and buy new shoes.”

https://www.thestar.com/news/canada/2017/11/17/formerly-homeless-theyre-now-advising-doctors-drafting-canadas-street-health-guidelines.html