As an individual with lived experiences of precarious housing, I understand how homelessness impacts physical, mental, and social wellbeing. My experience motivated my work in mental health, addictions, and precarious housing, and I’ve worked in health systems to change our approach to the homelessness crisis in Canada. My journey started at St. Joseph’s Healthcare, where I worked with a team of administrators, clinicians, and youths to improve accessibility to healthcare services for marginalized individuals. Over time, I recognized the need for policy and education reform to address the homelessness crisis. To address the housing insecurity, the Federal and Municipal Housing policy must implement the Housing First Policy to provide a safe place for people to live first rather than securing shelter contingent on abstinence. Furthermore, homeless health curriculum must be integrated into post-secondary health professional programs to train a generation of culturally sensitive and competent healthcare workers.

Precarious housing has become a public health crisis in Canada, and it is estimated that 25,000 to 35,000 people experience homelessness on any given night[1]. Risk factors such as unstable employment, low wages, and declining public assistance have exacerbated the issue[2].  Our current approach to the homelessness crisis does not adequately address the underlying cause of homelessness and requires major policy and education reforms.

Housing Policy Reform Based on Evidence-Based Medicine
The current approach to the homelessness crisis has prioritized increasing the baseline capacity to house people by utilizing Federal funding from the Ministry of Municipal Affairs and Housing to create public and affordable housing[3]. Access to supportive housing is largely limited to those compliant with treatment and substance abstinence, but the census indicates that 30~50% of homeless live with substance abuse or concurrent disorder[4]. The pre-existing policy limits the homeless population’s ability to access supportive housing, which is critical to reducing other risk factors for homelessness. The key difference in the Housing First approach to sustainable housing is to provide a safe place for people to live first rather than securing shelter contingent on abstinence. Studies have shown that the Housing First policy improves housing stability; reduces unnecessary emergency visits and hospitalization; improves physical and mental health outcomes and the stabilization or reduction of addictions symptoms; reduces involvement with police and criminal justice systems; and improves the quality of life[5]. Preliminary findings from the At Home/Chez Soi project, which compared the Housing First Program compared to standard treatment, showed the following results in favour of the Housing First group: 7,497 fewer nights in institutions (largely residential addiction treatment); 42,078 fewer nights in shelters; 6,904 fewer nights in transitional housing or group homes; 732 fewer emergency department visits; 460 fewer police detentions; 1,260 fewer outpatient visits; and 34,178 fewer drop-in-center visits. As such, a patient-centred approach that prioritizes the treatment of the underlying cause of precarious housing is a policy reform required to address the gap in our current approach to the homelessness crisis[5].

Training Generations of Competent and Culturally Safe Healthcare Providers Through Education
Healthcare workers, including primary and emergency physicians, are the first point of care for homeless individuals and often assume the role of coordinating interdisciplinary care. Experienced health providers know how to start optimal medical treatment, screen for mental health and addictions, and connect the individual with the necessary resources to stay healthy[1]. Starting appropriate management in the homeless population can be especially challenging for new professionals due to medical complexity, including pre-existing/chronic conditions, medical-legal concerns, cultural factors, ethnic values, and language barriers[6]-[7]. As learners, the key to becoming a knowledgable and respectful care provider is through education, mentorship, clinical practice, and feedback[8]. Unfortunately, medical learners receive limited education in working with homeless populations throughout their training[9]. This is reaffirmed by the survey of eleven Canadian medical schools, where 54% of the respondents saw the need for more focused curriculum development on homeless health topics, and 45% mentioned that their education minimally or did not relate to homelessness. This knowledge gap in training could lead to harmful experiences for the health professionals and individuals receiving care. From the health professional’s perspective, inadequate training could lead to a traumatic experience that impacts their mental health and motivation to provide optimal care to homeless individuals. For the homeless person receiving care, the first interaction sets the foundation to restore the broken trust with the system to provide a stable basis for recovery.

The homelessness crisis in Canada is more than an economic issue and must take a biosocial approach to address two key issues: (1) limited access to sustainable housing due to mental health addictions and (2) lack of trained health professionals who can provide competent and culturally safe care.

Establishing an Evidence-Based National Social Housing Policy
Homeless populations have a higher risk of substance use disorder as substances are used as a coping mechanism for harsh living conditions, stress, and trauma. Despite the high prevalence of substance use, abstinence is a requirement for most social housing across Canada[11]. To address this issue, implementing Housing First Policy supported by the Federal and Municipal governments will help reduce homeless people’s barriers to accessing social housing. The Housing First approach is a recovery-oriented approach to homelessness and is operationalized in the following manner: (1) individuals are given the option of housing without it being conditional on any lifestyle, behavioural or treatment expectations; (2) individuals provide feedback on type and location of the housing; (3) individuals are offered social housing as fast as possible, minimizing the gap between absolute homelessness and emergency services; and (4) individuals are offered ongoing support and services, including rent supplements, case management, and relationship building with the community. There are several benefits to Housing First Policy. First, individuals have immediate access to permanent housing with no housing readiness requirements. Second, the Housing First policy is a rights-based approach to give clients autonomy in choosing their housing and support, enabling them to sustainably participate in social, recreational, educational, occupational, and vocational activities. Third, the Housing First Policy helps individuals integrate themselves into their community by choice. This allows individuals to access housing that does not isolate or stigmatize the client and provides opportunities to engage in community-based social and cultural engagement through employment, cultural, and recreation activities. Enacting this policy requires approval from the Federal government and coordination at the Municipal level to reform the existing supportive housing policy.

Developing an Interdisciplinary Homeless Health Curriculum
A critical gap in caring for the homeless is the medical management of health issues. To address this issue, there is a need for a National Area of Focused competency in homeless Health Education. The target audience includes all licensed health professional programs in Canada, and topics should teach learners about case management and culturally appropriate care. In the context of comprehensive medical care, the key curriculum should include income assistance, management of physical and mental health, treatment of substance abuse through a harm reduction approach, and case management with an interdisciplinary team to integrate the individual into the community. The curriculum can be delivered through a combination of community-based and didactic learning. The goal of the focused competency program in interdisciplinary care is to train healthcare workers who can take on the following roles[2]: (1) Homeless Health Expert: to provide patient-centred care to homeless patients to improve health-related outcomes; (2) Advocate: to address the social and policy challenges beyond the clinical environment to address the systemic barriers; (3) Profesional: to demonstrate behaviour that shows commitment to excellence by adhering to the ethical standards set by physician regulators; (4) Leader: to work at the frontline to create meaningful change that has a lasting impact on the individual; (5) Scholar: to create and share knowledge to improve health providers’ perception, understanding, and intervention to improve homeless health; (6) Communicator: to engage patients experiencing homelessness to identify, understand, and improve their physical and mental wellbeing.

Precarious housing has become a public health crisis in Canada, and it is estimated that 25,000 to 35,000 people experience homelessness on any given night. Social, health and economic factors such as unstable employment, low wages, lack of affordable housing, and low education can increase the risks of homelessness. Canada’s supportive housing policy is focused on reducing precarious housing by increasing the baseline capacity to house people. This is done by utilizing Federal funding to create public and affordable housing across Canada. Unfortunately, this pre-existing policy does not provide a sustainable solution to address the underlying issue by eliminating risk factors for homelessness. To address the housing insecurity, two solutions are proposed (1) the Federal and Municipal Housing policy must implement the Housing First Policy to provide a safe place for people to live first rather than securing shelter contingent on abstinence, and (2) homeless health curriculum must be integrated into post-secondary health professional programs to train a generation of culturally sensitive and competent healthcare workers. Both proposals are innovative and pragmatic solutions to address a growing issue in our communities, and implementing them will require a coordinated collaboration among government, health agencies, and community services.

Numerous proposals have been developed over the years to address the homelessness crisis in Canada, but only a few take a recovery-oriented approach to address the underlying cause of homelessness. Both proposals outlined above integrate a rights-based approach to addressing the homelessness crisis by (1) increasing access to supportive housing through implementing the Housing First Policy and (2) training generations of healthcare professionals through educational reform. The first proposal focuses on developing resiliency by implementing a policy that enables the homeless to live in a safe environment while simultaneously addressing concurrent disorders and encouraging community integration. Taking a grassroots approach and bringing together Federal and Municipal governments with community housing programs to mandate Housing First Policy has never been done. This proposal offers a pragmatic and sustainable solution to create an environment where the homeless have reduced exposure to factors causing homelessness. The second proposal aims to create a focused homeless health curriculum in post-secondary health professional programs with the goal of training a generation of competent, respectful, and culturally safe healthcare providers. Across all health disciplines, an interdisciplinary homeless health curriculum has never been developed to train learners on managing homeless health. Developing an effective interdisciplinary curriculum will require collaboration between governments, educational institutions, and regulatory bodies to train learners with the outcome of increasing the number of competent health professionals in the field of homeless health. Ultimately, both proposals are innovative, sustainable, and pragmatic solutions to address a growing issue within the communities. Implementing both policies will require a coordinated collaboration among numerous stakeholders across Canada. It is important to recognize our current approach to the homelessness crisis has promoted national organizations to work in parallel, but our solutions offer a multidisciplinary and collaborative approach to improve the health and wellbeing of vulnerable members of our communities.