CAEP position statement on improving emergency care for persons experiencing homelessness: executive summary.

Homelessness is an emergency

On any given night, about 35,000 people experience homelessness in Canada [1]. Homelessness is associated with substantially higher mortality, with rates up to eight times higher for men [2] and 32 times higher for women compared to people of similar age (Table 1) [3]. Despite this risk, homelessness remains underrecognized. As first responders in public health crises and working at a critical intersection of health systems, emergency department (ED) care providers are in a unique position to intervene.

Table 1

Definitions of homelessness and housing exclusion [35, 36]

adapted from the Indigenous Definition of Homelessness in Canada and the Canadian Observatory on Homelessness.

Terms	Definition	Examples and descriptions
Homelessness	Lacking stable, permanent, appropriate housing, or the immediate prospect, means and ability of acquiring it
Indigenous definition of homelessness	First Nations, Métis and Inuit individuals, families or communities experiencing homelessness as described through a composite lens of Indigenous worldviews	Includes isolation from Indigenous peoples’ relationships to land, water, place, family, kin, each other, animals, cultures, languages and identities
Unsheltered, Absolute homelessness	Lack of housing and residing in places not intended for human habitation	Living on public sidewalks or parks (“street homelessness”), in tents, vehicles, or unsafe vacant buildings
Emergency sheltered	Residing in temporary, institutional shelters	Emergency overnight shelters, shelters for people impacted by family violence
Provisionally accommodated	Living in temporary housing without a prospect of permanence, including interim housing and “hidden homelessness”	Residing in prisons, group homes, or other institutions without housing upon leaving; recently arrived immigrants and refugees without means to obtain permanent housing
Hidden homelessness	Living temporarily with others without means to obtain permanent housing	“couch surfing”, living with an abusive partner; living in hostels, motels, and rooming houses
Transitional housing, Interim housing	Systems-supported bridge housing between living unsheltered and permanent housing, usually offering time-limited housing security	Housing program offering more privacy, employment pathways, and case management; housing for individuals or families impacted by violence offering trauma-recovery support
At-risk of homelessness, Relative homelessness	Living in housing intended for permanent habitation with economic or housing precarity, or conditions that do not meet health and safety standards	Overcrowding, inadequate heating, sudden unemployment, households facing eviction, violent or abusive situation, institutional care that is unsuitable

ED visits are often related to acute exacerbations of chronic health conditions or medical complications of being homeless [4]. Compared to the general population, people experiencing homelessness have higher rates of cardiovascular disease, traumatic brain injury, cancer, and other illnesses that are core to emergency care [5-7]. As a result of poor living conditions, they are also at increased risk of exposure to infectious diseases (e.g., COVID-19, HIV, and hepatitis C) yet face barriers to accessing appropriate care [8, 9].

ED visits are an opportunity to prevent health and housing emergencies. Studies indicate that people experiencing homelessness present to EDs over 8 times more often than matched cohorts [8], but also reveal that hospitals experienced at managing homelessness were less likely to have readmissions or return visits [10]. When people were housed, ED visits declined as well [11, 12].

ED providers are committed to caring for people experiencing homelessness, but may face moral distress in feeling unable to identify effective interventions. This strain can lead to inaction. In working towards ending homelessness and its impact on our patients, we can take advantage of a range of innovative approaches to care, evidence-informed practices, and our health system leadership (Fig. 1).

Fig. 1

Summary of interventions along the care pathway

CAEP position on homelessness

The Canadian Association of Emergency Physicians (CAEP):

Recognizes that people experiencing homelessness are at higher risk of acute illness and death

Affirms that people experiencing homelessness should receive supportive care and planning in the ED that avoids involuntary discharge into homelessness

Encourages ED care providers to:

adopt a trauma-informed approach for all care;

recognize when homelessness or unstable housing contributes to the ED visit;

facilitate access to services that address determinants of health and offer referral to social service providers; and

identify substance use disorders, when present, and offer management and harm reduction.

Advocates for system-level policy changes toward an end to homelessness.

This position statement was developed with the participation of people with lived experience of homelessness and applies an ED perspective to the Canadian clinical guideline for homeless and vulnerably housed people [13]. Implementation of the approaches described should occur in partnership with affected individuals and communities and account for local resources, evolving knowledge and innovations in care. The complete statement can be found at https://caep.ca/advocacy/position-statements/.

A “trauma-informed” approach should be the foundation of ED care

The key underlying framework to addressing homelessness and its complications is applying a trauma- and violence-informed approach to all ED care. Whether working in triage and registration, at the bedside, or on ED resources and policies, embedding trauma-informed practices can improve outcomes [14].

Homelessness has severe health and social consequences: surviving despite these challenges requires immense resilience to hardship. Many people experiencing homelessness suffer the effects of psychological and/or physical trauma which can profoundly affect their interactions with care providers.

Trauma arises from events experienced by individuals or communities as physically or emotionally harmful and has lasting adverse effects on functioning and physical, social, emotional, or spiritual well-being [15]. For example, adverse childhood events are associated with increased morbidity, mortality, and health care utilization [16].

A key feature of traumatic events is the loss of control. To avoid this, ED care providers can empower patients by following four principles [17]:

Understand that trauma and violence affect people's lives and behaviors,

Create emotionally and physically safe environments,

Foster opportunities for choice, collaboration and connection,

Provide a strengths-based and capacity-building approach to support coping and resilience.

Taking a trauma-informed approach can also foster safer environments for both providers and patients [18]. Integration of these principles into ED care [19] and nursing education [20] corresponds to key training milestones [21] and reflect a paradigm shift from “What is wrong with you?” to “What happened to you?” Care providers may also experience trauma in their own lives, including in the workplace, which contributes to compassion fatigue [19]. Recognizing when behaviors are associated with trauma can facilitate de-escalation, improve the quality and safety of care, and reduce the risk of re-traumatization.

Interventions can be taken to diagnose, manage, and prevent homelessness in the ED

As evidence-based clinicians, CAEP supports the improved identification and management of homelessness in order to improve the health of people at high risk for mortality. Understanding the extent of the problem includes accurate registration of patient demographics, recording relevant social history, and applying a diagnosis of “homelessness” or “inadequate housing” when they contribute to the ED visit with standard ICD-10 diagnostic codes Z59.0 or Z59.1, respectively [22].

ED management should address gaps in basic needs, such as dehydration, malnutrition, exposure, sleep deprivation, and poor hygiene. Clinicians should consider whether these complications of homelessness contribute to the clinical presentation. For example, from the patient perspective, extreme thirst and hunger likely take priority over laboratory tests. Attending to these needs is part of the trauma-informed approach and can permit patients to engage with other ED care.

People experiencing homelessness who use substances may benefit from support resources or pharmacologic interventions. Patients face barriers to housing when emergency shelters, long-term care facilities, or social programs prohibit substance use or possession of harm reduction supplies. Appropriate management of intoxication, withdrawal and pain can mitigate premature discharges and facilitate linkage to resources [23, 24]. For example, patients with an opioid use disorder can be offered a naloxone kit and opioid agonist therapy; patients with alcohol use disorders can be offered medications for craving reduction [25, 26].

Inclusion of people with lived experience of homelessness in developing ED care pathways and providing care directly can promote a safer environment, increase the effectiveness of care, and improve trust [14, 27, 28]. For these reasons, hospitals have begun to employ peer workers to support patients in the ED.

A selection of additional interventions can be found in Table 2 and the supplementary materials and a recent literature review in CJEM includes examples of ED initiated programs [29].

Table 2

Selected ED interventions. A complete summary and examples can be found at https://caep.ca/advocacy/position-statements/

Situation	Context	Interventions and Examples
All ED care	Promote safer environment for patients and providers	Trauma-informed approach e.g., avoid rigid enforcement of rules that are not immediately needed for safety, allow flexibility in management plans to establish trust, attend to basic needs. More examples: Alberta Health Services module [34]
All ED care	Homelessness is associated with severe deprivation	Attend to basic needs: address dehydration, malnutrition, sleep deprivation, personal hygiene, e.g., offer food, access to shower facilities, appropriate clothing
All ED care	Homelessness is underrecognized	Identify homelessness through accurate registration of demographic, screening when appropriate (“Do you have a safe place to go?”), and as the diagnosis when contributory
Person identifies as experiencing homelessness	ED visit may be signal of high unmet needs	Assess interest in housing and income interventions. Early involvement of allied health professionals and community resources when appropriate
Person identifies as Indigenous	May experience effects of racism and inter-generational trauma	Culturally appropriate care to advance good relations, e.g., applying protocols for clinical care: “situating one’s self”, “visiting”, “hospitality”, and “treat people as you would treat your own relative” [37], implementing TRC recommendations for health care [38], San’yas training program: sanyas.ca
Person identifies as a woman	More likely to experience poverty, sole parenthood, sexual abuse or trafficking	Consider screening for gender-based abuse and violence Consider resources available for women and families
Person who uses drugs / substance use disorder	Risk of complications from substance use. May have barriers to housing	Management of substance use, withdrawal and untreated pain, e.g., offer naloxone [24], information on supervised consumption, anti-craving medications, etc
Individual or family at high risk of homelessness	e.g., “couch surfing”, recent eviction notice, sudden loss of income, etc	Early referral to social worker, case manager, housing coordinator, or community agency. Application for income supports, rent bank funds, access to housing for families, etc
Disposition planning	Effective planning can improve quality of care and reduce length of stay and return visits	As needed, facilitate access to identity documents, alternate pathways and back-up plans for follow-up, medications, and resources to manage illness in the community, e.g., dispense supply of medications, program to supply reused mobile phones [39], referral to respite care, etc
ED policies and pathways	Promote trust and positive interactions, reduce stigma [14, 27, 28]	Involve people with lived experience of homelessness to provide insights, inform design, and establish community relationships. Appropriately compensate participation
Advocacy to end homelessness	Upstream action is needed to prevent housing emergencies	Advocate and partner with individuals and communities for structural change by leveraging ED care provider professional skills, relationships, and resources

EDs provide a bridge to essential resources

Along with addressing health needs, ED care providers can assess patients experiencing homelessness for interest in housing and/or income resources. Early referral to providers familiar with these resources, such as social workers, case managers, and community agencies, can help to optimize care.

The diversity of homelessness experiences requires tailored strategies for different needs in the same way that arrhythmia management is tailored to clinical features and risk factors. Resources may be available based on factors such as housing situation, age, gender, sexual orientation, parenthood, exposure to violence, migration status, disability, or ethnicity (Table 2). Respectful inquiry or screening can help to avoid cognitive biases that lead to medical errors or under-identify forms of homelessness [30].

Bridging to resources is also an important perquisite for safe disposition from the ED that avoids unnecessary return visits. For example, patients may need assistance with replacing identity documents, developing linkages to follow-up care, obtaining income and health benefits, and obtaining medications. Clinicians play an important role in collaborating with patients to anticipate and identify these challenges to support disposition plans.

EDs can be a source of leadership to end homelessness

Homelessness is an unacceptable condition for health and human dignity, especially in a nation as wealthy as Canada. Across the country, nearly 1 in 8 households live with unsuitable, inadequate or unaffordable housing [31]. Although meaningful steps can be taken to mitigate its harmful complications in the ED, a permanent end to homelessness must be achieved with broader support. Beyond high-quality ED care in safe spaces, upstream systemic approaches are necessary to prevent crises of homelessness from becoming emergencies.

ED care providers can leverage their professional skills, insights, and resources to advocate for an end to homelessness to health institutions and governments at all levels [32, 33]. As influential members of society, we are privileged with the trust of the public and can enact change in partnership with patients and communities. Partnership ensures that resources are directed towards priority needs. Advocacy in this spirit is facilitated by amplifying marginalized voices and providing ownership, opportunities, credit, and adequate remuneration to people with lived experience of homelessness.

From our position as clinicians, we can also correct misrepresentations and promote understanding of the strengths of people experiencing homelessness. Leveraging our knowledge of science, we can call attention to evidence-based interventions such as “Housing First” [34], which emphasizes the expansion of permanent supportive housing to improve both housing and health system outcomes.

As ED care providers, we bear witness to problems created by failures of prevention, gaps in policy, and inter-generational inequities of health and well-being. CAEP recognizes opportunities for action outside the ED and advocates for system-level change to prevent and end homelessness.

Conclusion

Housing is necessary for health. By addressing this key social determinant, ED care providers have an opportunity to manage a crisis condition that often triggers ED visits. Collectively, we should strive to never discharge a patient from the ED into homelessness. While we work towards this goal, we can intervene to provide high-quality patient-centred acute illness management, facilitate access to essential resources, and demonstrate leadership to prevent and end homelessness.

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 17 KB)