Hospitals and Homelessness

Dr Jim Frankish et al., University of British Columbia (2010)

This study focused on the experiences of homeless clients and service providers at St. Paul's Hospital in Vancouver, British Columbia.


  • Homeless and at-risk persons may receive different treatment (from hospitals) than other hospital users, but these experiences in the hospital situation are not well known.
  • Homelessness increases the use of emergency health services, the most expensive health service.
  • People who are homeless and have concurrent diagnoses (for example, both a mental illness and substance abuse) are most likely to use emergency health services.
  • Service providers report challenges in both referring and receiving homeless people from hospitals.

What was done in this research project?

A literature review, a survey with homeless people, interviews with service providers as well as health professionals at St. Paul's Hospital, and a medical chart review of patients from St. Paul's Hospital with no fixed address. In this study, health services included emergency room visits, out-patient visits and in-patient hospitalizations.

Who is included in this study?

Residents of shelters or transitional housing in Vancouver; individuals with no fixed address, such as those staying with friends or relatives for brief periods of time (e.g., "couch-surfing"); shelter and service providers; and health professionals at St. Paul's Hospital.

Results from the literature on homeless people in emergency departments

  • Homeless people in the emergency room are more likely to be male, younger, less educated, and from First Nations.
  • Homelessness is widespread among emergency room patients.
  • Homeless clients spend more time in the emergency room of hospitals and are less likely than others to be admitted to the hospital.
  • These clients spend a great deal of time on survival needs and, as a result, tend to ignore their health.
  • They feel unwelcome in emergency rooms, yet this is their main health care option.
  • They tend not to use health care for various reasons ranging from feeling stigmatized to difficulty finding transportation to the hospital.
  • Supportive housing may significantly reduce the number and cost of hospital visits.

Survey results for homeless people

  • Three-quarters said that their health was between fair and very poor.
  • In the previous month:
    • 59% went to a drop-in clinic
    • 54% were at a hospital emergency department
    • 50% were treated by a family doctor
    • 30% were a hospital in-patient
    • 21.3% saw nurses/staff at homeless shelter
    • 20% saw street nurses
    • 11% were a hospital out-patient
    • 1% saw someone like a psychiatrist
    • 8% had no medical care.
  • Visits to the hospital in the previous 6 months:
    • 29% – once
    • 20% – twice
    • 30% – 3 to 5 times
    • 21% – 6 to 20 times.
  • Transportation to St. Paul's Hospital:
    • 48% of the participants were taken to the hospital by ambulance
    • 21% by Safe Ride Footnote 1
    • 16% walked
    • 8% by bus
    • 4% by taxi
    • 2.5% by a friend's car
    • 1% rode his/her bike.
  • Many participants were satisfied with the care that they received at the hospital, felt that they were treated respectfully, and did not have to wait too long to be seen.
  • Some felt that they were treated poorly, (escorted out by security before being seen), or that they had to hide the fact that they were homeless in order to get proper treatment.

Data from Homeless Clients' Medical Charts

  • The most common complaints were gastro-intestinal or respiratory.
  • 33% of clients had a social-worker referral on their chart mostly for transportation issues, followed by housing issues.
  • 31% of the patients had mental health issues, 31% had distinct addiction issues, and 12% had both types of issues.
  • Clients visited the emergency room between 1 and 32 times in the 12 month period of this research.

Views from Health Professionals

  • Homeless clients tended to come in with a range of complaints, because they were cold or they needed new clothes.
  • Because of the nature of emergency care, health personnel tended to focus on the issue clients outlined, rather than include a spectrum of issues.
  • Most did not know how homeless clients arrived at the emergency department. Some suggestions were Safe Ride, bus, bicycle, walking or ambulance.
  • They felt that these clients were more likely to be admitted in order to have a place to stay.
  • The emergency department was a "revolving door" where homeless clients came in for an issue, were sent to another provider to deal with it and ended up back at emergency for the same issue.
  • Staff was empathetic toward homeless clients and had knowledge of other resources they could use.
  • Some staff became desensitized when they saw the same homeless clients repeatedly.
  • Communication with homeless service providers could be improved.

Views from Service Providers

  • Their clients went to the hospital by ambulance or Safe Ride.
  • They followed up with the clients at the hospital and with social workers.
  • They felt that the conditions that their clients went to the hospital for were often not appropriate for an emergency room.
  • Some advocated for their clients; some developed relationships with hospital staff.
  • Some reported that a new clinical housing team that goes to all of the Housing First projects as being effective, as this approach allows clients to be helped before a health crisis.
  • Barriers to care:
    • Clients with mental health issues having to wait in crowded waiting rooms.
    • Stigma around others being able to tell the patients were homeless.
    • Safe Ride – they would refuse to take people for what they saw as minor issues such as wound care.
  • Clients were often discharged too soon.
  • Clients did not always tell the truth about their medical issues to service providers.
  • More communication between the hospital and housing staff would help improve patient outcomes.

Findings and Recommendations

  • There are differences in perceptions between homeless service providers, health care professionals and homeless clients.
  • Sensitivity training for health care professionals and increased communication between health care professionals and homelessness service providers would be beneficial.
  • Patients are often discharged with verbal instructions; detailed written instructions would be helpful.
  • 73% of homeless people do not fill their prescriptions. If they are aware of the prescriptions, service providers can work with pharmacists to fix this issue.

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