The reality of health care and homelessness

Posted on August 12, 2016 in Social Security Debates – Opinion/Commentary – The only solution for some patients is to build new homeless shelters
Aug. 12, 2016.   By SHAURYA TARAN

On the wards in St. Michael’s Hospital, you will find some of Toronto’s most underprivileged inner-city patients. Mr. Levy is one of them. He is a middle-aged homeless man with a failing heart and end-stage kidney disease, who requires hemodialysis three times per week to sustain his basic bodily functions. A survivor of severe PTSD, he self-medicates with heroin and fentanyl purchased illegally off the street.

Unlike many patients, Mr. Levy cannot return home at the end of his dialysis sessions. The only place he can go is the street. Here he is free to pursue his drug habits: inject heroin and fentanyl with recycled needles and sniff gas fumes for a cheap high. Mr. Levy is often found by paramedics in a half-conscious stupor, curled up on a street corner, a city park bench, or a backside alley. The paramedics then dust him off and bring him by ambulance to the hospital for treatment.

If Mr. Levy misses dialysis he will need an urgent hospital admission to save his life. Over the past year alone, Mr. Levy has required close to two dozen urgent hospital admissions for missed dialysis sessions. The nurses in the Emergency Room all recognize him. They do not need permission from the doctors to implement the “Levy protocol,” which involves looking for signs of physical injury, checking his pupils for opioid intoxication, performing a neurologic exam, and sending off a drug screen. On each visit he will be admitted to the Nephrology ward and kept for a day or two before being discharged. No one knows when he will return, but it will happen. It’s just a matter of time.

As an internal medicine resident, I have already cared for Mr. Levy twice in my two-week placement on the Nephrology service. Like others before me, I have been puzzled by his repeated admissions. I have also expressed frustration with the inefficient, resource-intensive, and symptom-targeted approach to his care.

Mr. Levy’s vulnerable, inner-city status predisposes him to receive fragmented medical care, but that doesn’t mean efforts to help him have been scarce or half-hearted. His hospital records show he has been seen by social workers, rehabilitation experts, outreach supervisors, community care nurses, and discharge planners. Everyone has tried and failed to find him a suitable long-term home. Bed shortages, wait lists, and exclusion criteria have prevented his acceptance into any one of the city’s handful of homeless shelters. After so many unsuccessful attempts, no one is optimistic about his chances anymore.

With every admission to St. Michael’s Hospital, Mr. Levy costs the health-care system thousands of dollars. He is what we call in medicine the “social admission:” a patient whose care and discharge are complicated not by medical factors, but by factors such as difficult living situation or financial condition. Although each admission saves Mr. Levy’s life, it does not bring him any closer to a meaningful recovery. Nor does it offer any solution to his homelessness — the true root of his problems.

The best solution is also the simplest one: find Mr. Levy a home and end his cycle of hospital admissions. One way to accomplish this is simply to build more homeless shelters. There has been much talk about expanding the network of homeless shelters in Toronto, but no concrete actions have been taken. This must change soon.

Toronto has a large inner-city population, and patients such as Mr. Levy account for a large proportion of health-care spending with their recurrent admissions and high-care needs. Homeless shelters will effectively remove these patients from the street. They may also provide a more predictable daily routine. For a patient like Mr. Levy, this may mean more regular dialysis, fewer drug overdoses and related complications, and better social support. For the health care system, this may translate into less superfluous spending on avoidable admissions.

In our relatively well-to-do city, patients like Mr. Levy are treated as outliers. They are shuffled back and forth in an unsustainable limbo between the street and the hospital. This cannot continue. If we cannot adequately care for our city’s most vulnerable members, then we must accept responsibility for their enormous care costs. Otherwise, we can choose to invest in more homeless shelters, tackling the issue at its core. Our collective response may save Mr. Levy from another senseless hospital admission — or two, or three, or maybe even a dozen.
Shaurya Taran is an internal medicine resident at the University of Toronto. The name of the patient and certain details have been changed to preserve anonymity.

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One Response to “The reality of health care and homelessness”

  1. Amanda says:

    Dear Editor,
    I agree with your opinion on needing more support for the homeless population. The problem is not the medical care Mr. Levy is receiving, which leads him into multiple hospital admissions. The problem is the lack of outside support (such as homeless shelters) which ends up costing the health-care system extra expenditures which are unnecessary. And this is most likely the case for many other homeless individuals in Toronto. As stated, an increase of homeless shelters is the answer to this re-occurring issue, which will provide the vulnerable population a more predictable daily routine and better social support. Yet, Medicare operates within the traditional medical model where the focus is more on cure than prevention, otherwise known as a Band-Aid solution. The preventive steps towards housing the homeless through investing in affordable housing and housing initiatives may cost less for the health-care system then constantly treating re-occurring, relatively preventable health related issues.


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