Acute Health Care Perspectives on Homelessness Research Making Data Meaningful April 23, 2015 Ginetta Salvalaggio, MSc, MD, CCFP Assistant Professor, University of Alberta Research Director, Inner City Health and Wellness Program

Why health care needs to look upstream  Mortality  Physical Health  Mental Health  Disability  Cost

But isn’t acute care WAY downstream?  The hospital is the only place where care is available 24 hours a day without an appointment  The hospital is an important access point for homeless patients  Some patients may be presenting to the hospital for food, shelter and/or safety reasons  Effective community solutions have limited reach in acute care settings

Current state of services High acute care use Patient factors Acute care service priorities Community supports

Challenging assumptions  Administrative data, without context, give a partial picture at best (and an inaccurate picture at worst)  Top down implementation of new services is unethical  Harm reduction: “Nothing about us without us”

Ask the patient… Alcohol and Drug Use

Ask the patient… Reasons for hospital visit

Ask the patient… Need for additional services

Key Lessons  Many patients presenting to the hospital with substance use related concerns and/or unstable housing are trying to reduce their alcohol and drug use  Patients are interested in accessing additional addiction, housing and mental health related services at the hospital

What might the solution look like?

Ideal state of services Reduced acute care use Patient factors comprehensively addressed Enhanced team embedded in acute care Connection to community supports

Elements of the intervention  In-hospital stabilization and health promotion  Brokered access to less costly service environments  Care coordination and discharge planning  RELATIONSHIP

Implementation to date Since July, 2014:  ARCH team has completed >600 new consults  ARCH team sees ~20 consults weekly  Referrals from multiple services and units  Close attention to intervention reach and fidelity

Who are we seeing? 73% active tobacco use 63% high risk alcohol consumption 45% active drug use 25% up-to-date vaccination status 49% recent HIV testing 42% screen positive for depression 47% no regular legally obtained income 47% no stable, safe housing

Patient oriented outcomes  High ED use  Family practice-sensitive ED use  Primary care attachment  Substance use stabilization  Health promotion  Social stabilization  Perceived unmet care needs

Data sources  Patients  Baseline, 6 months, and 12 months  Intervention group and comparison group  Administrative data  Health  Income Support  Housing

Critical partnership #1: Community  > 10 year relationship  Multiple roles  Team orientation  Secondment of peer outreach workers  Clinical and scientific direction  Knowledge exchange  Population access  Research relevance and credibility  >50% retention rate

Critical partnership #2: Data  Lengthy preparation for data pulls  Data management and linkage protocol in place  Priorities shared by custodians, researchers, patients, and stakeholders  Identified benefits to both parties

Critical partnership #3: Stakeholder engagement  Extensive consultation  Real time communication and collaboration  Commitment to knowledge sharing  Hospital leadership as champion  Formal process evaluation

Knowledge Translation Stakeholder Engagement Local Patient Data Process Outcomes Learning Collaborative Local Care Context What is needed here?

Acute Health Care Perspectives on Homelessness Research Making Data Meaningful April 23, 2015 Ginetta Salvalaggio, MSc, MD, CCFP Assistant Professor, University of Alberta Research Director, Inner City Health and Wellness Program