Rethinking traditional models of care
35,000 Canadians are homeless on any given night. On the streets of downtown Ottawa, it isn’t unusual to see them huddled for warmth against a building, their belongings beside them.
Sometimes a hand-drawn sign on a piece of cardboard identifies them by its message: “homeless in need of food,” or, more poignantly, “I used to be your neighbour.”
Even without the sign, you recognize them instantly.
In Ottawa alone, a city of about 900,000, there were approximately 6,700 people that used shelters in 2013. Some move from shelter to shelter seeking a place to sleep and a warm meal. Many are chronically ill but won’t or can’t seek care at a hospital.
Some have been victims of abuse. Others suffer from addiction, mental illness or both.
Their diversity is a reminder that homelessness can happen to anyone.
The Ottawa Hospital and Ottawa Inner City Health (OICH) are tackling the issue of homelessness head on by helping to improve the health of the homeless population through innovative, community-based care.
The dedicated staff and volunteers of the OICH have successfully integrated a population health approach into the design and delivery of care for the homeless. In doing so, they’re helping us to rethink traditional models of care.
The work of the OICH is identified in CIHI’s Population Health and Canada’s Health System, a study that sought out health system leaders who are applying the population health approach in a health care setting. The year-long study was part of an initiative by CIHI to start a dialogue in Canada that would enhance the capacity and interest of health system leaders to apply a population health perspective to health system planning and decision-making.
At the heart of all of the OICH programs is the idea that taking health care into the community and delivering it in ways that are relevant to unique needs can vastly improve access and continuity of care for hard-to-reach populations like the homeless people of Ottawa.
The population health approach in action
OICH was established in 2001 by The Ottawa Hospital and other community and health leaders who were concerned about a group within Ottawa’s homeless population.
Despite their frequent use of health services, this group of shelter users had complex health needs and were not well cared for.
Today, OICH operates a number of programs, including those that provide medical care, mental health services, addiction services and palliative care. These services are delivered in shelters and residential settings supported by partner organizations, as well as partnerships with the Ottawa Police and other social services providers.
In this way, OICH’s services form a connected suite of services that simultaneously address the multiple health needs of the homeless population in Ottawa.
A hospital without walls
Through OICH, The Ottawa Hospital has been called a “hospital without walls,” because health services are actually based in the community.
“We deliver services in the shelters, and we partner with those shelters, but it’s The Ottawa Hospital reaching out into its community,” says Dr. Jeff Turnbull, chief of staff at The Ottawa Hospital and medical director of OICH. Along with OICH’s executive director Wendy Muckle, Turnbull is one of the OICH founders.
They describe the patient population they deal with as very sick, vulnerable, not trusting of the system, and not willing or able to go to the hospital.
And so, OICH and its dedicated team of professionals take the hospital—and its care and services—out into the community.
OICH has 7 different programs including a managed alcohol program, a program for women, a Targeted Engagement and Diversion (TED) program, a hospice, a primary care clinic and a special care unit for men. The programs are delivered across 5 different shelters and residential settings. There are 200 beds in total. In addition, there are 2 housing programs in the west end of the city.
A different approach to care
How is this approach to care different? Turnbull explains it this way: “Traditionally, we have an approach that we say one size fits all… this moves the care to a more patient-centred or client-centred approach. It takes a unique population and says, ‘How can we bring care to you, on your terms?’”
Funded in part by the Local Health Integration Network (LHIN) and partner organizations, including Ontario’s Ministry of Health and Long-Term Care, OICH is an excellent example of how health system leaders in Canada are integrating the population health approach into their operational planning and decision-making processes.
“The future should not be centred around the hospital,” says Dr. Jack Kitts, Ottawa Hospital president and CEO, who played an instrumental role in securing funding for OICH. “These are patients who do not necessarily come to the hospital to be admitted for acute care problems, which is what hospitals do. But these were patients who could not be managed in the community, in primary care, weren’t sick enough for the hospital, but there was no place to go.”
For a program like this to be successful, strong leadership is important, both for generating buy-in and for navigating policy and funding issues. Partnerships are also critical. They help maximize program impact and ensure that resources are leveraged.
“We’re working with ambulance services and paramedics and the police department. You can’t get the results unless you have everybody working together,” says Turnbull.
Good data, including common data definitions and standards that CIHI can provide, is also important to the success of the program, as it helps to identify specific populations with unmet needs, evaluate the effectiveness of interventions and strengthen the case for action.
The results, both in the community and on paper, speak for themselves. “Our entire program is a little under $4 million. The reason that our budget is as small as it is, is because we are able to leverage all these other resources from our partners. It doesn’t make any sense to build an infrastructure when you can use somebody else’s,” says Muckle.
“Any study, any evaluation that we’ve done,” she adds, “shows that at minimum you save $3 of taxpayers’ money for every dollar you spend. And people are healthier and they get better care. It’s pretty hard to argue against doing a better job and spending less money.”