The Current - Why a place to call home can be the best medicine

Episode Date: October 14, 2024

Over the past year, more than 4,000 visits to ERs in Toronto were made by a small group of 100 unhoused people. Now, the city’s University Health Network is supporting Dunn House, a project offering homes to people in that group, with onsite medical and social supports. 

In 2017, it felt like drugs were everywhere in the news, so I started a podcast called On Drugs. We covered a lot of ground over two seasons, but there are still so many more stories to tell. I'm Jeff Turner, and I'm back with Season 3 of On Drugs. And this time, it's going to get personal. I don't know who Sober Jeff is. I don't even know if I like that guy.

On Drugs is available now wherever you get your podcasts. This is a CBC Podcast. Hello, I'm Matt Galloway and this is The Current Podcast. Across this country, cities are grappling with a growing homeless population. In Toronto, over 10,000 people are unhoused each night and shelters in that city are over capacity. Many people end up in one of the city's emergency rooms. Dunn House, a new project combining housing and medicine, hopes to change that. It will be welcoming its first residents in a few weeks. This initiative is backed by Dr. Andrew Bazzari, who is executive

director of the Gattuso Center for Social Medicine at the University Health Network. Keith Hambly is the CEO of Fred Victor. It's a nonprofit organization that works with people who are unhoused, and they're both with me in our Toronto studio. Good morning to you both. Good morning. This is such an interesting idea, Andrew. And one of the interesting things about it is that, and we'll talk about what it's going to solve in a moment, but that it addresses a specific crisis that you see every day in the hospital, in the emergency department. Describe that situation in the ER and how often people who are unhoused come through those doors. Yeah. And I think Matt, as you've laid out that the homelessness crisis is only getting worse with over 10,000 people in the shelter system. And some of the

epidemiology around homelessness, we just have to be clear about that people who are unhoused live half as long as the general public or people who are housed. So that's a major health gap, probably no more powerful social determinant of health than housing when someone is losing 30 to 40 birthdays. And what we're seeing is that people who are unhoused chronically get more and more sick, which should not be surprising, but it's the reality that's playing out now for thousands of people in the city and for hundreds of thousands of people across the country. And so what's happening is people have chronic disease issues like diabetes.

They have higher rates and risks for cancer. And they're ending up in the emergency department, in some cases because they have nowhere else to go, or their healthcare conditions continue to deteriorate because they don't know where they're going to sleep this night or next. And trying to manage medications becomes a huge challenge on any chronic disease piece. And as we've seen more and more reports, there are people who are in the emergency department being diagnosed with cancers that are presenting because there's just been a lack of access to care. And the reality is that people are in this, we call it a revolving door, but it's really a doom loop for people between the street and the emergency department

and not being able to address the upstream issue, which is housing. There's a phrase that's often used to describe those people, frequent flyers. What do you make of that? I mean, part of it speaks to, in reading some of the research around this, at UHN, 100 patients without fixed addresses accounted for 4,309 emergency department visits over the past year. Yeah. When we continue to look at that data, there's 51 patients make up over 3,000 emergency department visits in each year. I don't like the term frequent flyers because I don't think anyone wants to be in the emergency department if they don't have to be. And it's something that we've had in medicine where we

talk about frequent flyers or bed blockers has been the usual vernacular of how we describe they're taking up space they're taking up space and no one wants to block a bed they're languishing in a bed because there isn't supportive housing or they're coming through the emergency department because there is nowhere else to go and i think to me the part of this initiative is trying to upend that narrative and that thinking around people being underserved and this really being about policy failures. I mean, we have discrimination steeped in the way that we treat people in poverty and medicine. So if I have my notebook and I'm seeing someone

who's unhoused and prescribed medication and you come back and see them in a week and they say, well, they haven't been able to take their medications because they haven't even known where they're going to be able to sleep, let alone store their medications. I have to write patient has been non-compliant with medication regimen. That is what we've been trained to do. But the reality is patient has been exposed to higher rates of death due to policy failures with no access to housing. There is, we don't talk about the cost. I want to talk about how this is going to work in addressing this, but we don't often talk about the cost of healthcare in this country because it's a universal, you know, you don't pay, you don't put the credit card out when you leave, but there is a cost, a

material cost to people who can't find help elsewhere coming into an emergency department, right? Absolutely. And I think we have to be really opening, transparent about these costs. And the realities are, one, that there's a huge human cost, which we've talked about in terms of the loss of life. And how do you capture and measure that? Or someone who ends up being palliative having to be receiving care or dying on the street as opposed to being able to die in a home? to die in a home. So I think there's a whole element of health economics we have to capture. But when you look at the costs for an emergency department versus a hospital admission piece, the one thing that I would lay out is that when we looked at the data, someone who's in the hospital that I work at for over a month would be over $30,000. That's a very conservative estimate.

Could it be close to $40,000 or $50,000? If they're in the prison system, which a dear friend, Lana Fredo, calls the de facto mental health system, that's about $10,000 or $50,000. If they're in the prison system, which a dear friend, Lana Fredo, calls the de facto mental health system, that's about $10,000 to $11,000 per month. And in the shelter system, it's about $6,000 to $7,000, where the cost for supportive housing are $3,500 to $4,000. So I think the cost breakdown, when we talk about can we afford this, I would push that we can't really afford the status quo. And so Keith, tell us how this idea, Dunn House, how is this going to address the crisis that Andrew has been laying? Well, I think it'll address the crisis. It is what it is. It is housing. It is deeply affordable, accessible housing for people who are in greatest need andrew outlined uh the broad issues that he is uh has seen at uhn that goes across the board across the city

of toronto and probably across canada too uh so what this housing does it provides a permanent supported and secure place to live in which a person can actually regain parts of their life, get connected to not just the health care that will be provided on site, but the community care that will exist in that building through staff, through connection to other local or neighborhood activities. And Andrew mentioned the medication component. I think we underestimate the impact when a person who is homeless goes to a hospital, goes to the emergency room, gets prescribed some sort of medication.

Where on earth are they taking that? They're taking it, trying to hide it in an encampment. They have no place to store it. And the systemic barrier that Andrew described is noncompliant. Unbelievable. Unbelievable that that's what is required to be put in there when in fact this person has no choice but to try to keep it somewhere but can't really, they don't have a choice in saying,

well, yeah, I'm going to keep it in a safe place while I don't have a safe place to live. So you give a little snapshot of it. This is how many housing units? 51 units. 51 units of permanent housing that are totally supported 24-7 with an array of staff that will do what? Mental health support service, harm reduction work, community engagement. Now, people will say, well, what's community engagement?

Well, that's everything from getting connected to the, as I said, broader community in the neighborhood in Parkdale where it's located. The connection, frankly, to those key elements of life, food security. There will be meals prepared on site, but staff will also be helping teach, if you will. And we'll bring in those who are experts in teaching how to cook, how to shop, how to find, in this city, how to find inexpensive food. In fact, there are amazing neighbors that have offered up garden plots and community garden plots come next spring for the tenants there. So this is all about rebuilding a person's life that has been shattered through a variety of trauma experiences in the system. In 2017, it felt like drugs were everywhere in the news. So I started

a podcast called On Drugs. We covered a lot of ground over two seasons, but there are still so many more stories to tell. I'm Jeff Turner, and I'm back with season three of On Drugs. And this time, it's going to get personal. I don't know who Sober Jeff is. I don't even know if I like that guy. On Drugs is available now wherever you get your podcasts. Can I just ask a practical question, which is in a city where housing is expensive for anybody, where's the space for this coming from? Well, the space, and I think this is part of the vision that Andrew had about five years ago, that UHN had land, a parking lot, and Andrew and his team convinced the board and convinced UHN and said, we need to do something. we need to do something.

We need to be a participant in solving this issue around homelessness, solving the issue around chronic revolving door ER visits and that sort of thing. And we have the ability, the power, and the land to do that. Coming together internally there at UHN, coming up with a model that integrated health care and housing together was a model that was you know in excited the city excited united way as as key partners and uh this particular project through the city's help through the rapid housing and initiative actually got it built you and i spoke about that five years ago when this idea was just kind of swirling around yeah it was a parking lot it was a parking

lot um in a city where there's, what did I say, over 10,000 people who are unhoused every single night, who are the people, some of the people who will be moving in to Dunn House? One of the things that we've wanted to see push and change, and especially, you know, where there's been the UHN leadership with the partners that Keith has mentioned, from Fred Victor to the City of Toronto and United Way, is how can this help prescribe housing for UHN the data around the highest health needs that would benefit from this holistic model in terms of both the social care piece, which Keith spoke really powerfully and tangibly to, but also the healthcare aspect. So there's a primary care clinic room that will be there that I will have the honor of working at in the coming weeks to work with tenants and patients, as well as psychiatry,

partnering with the inner city health associates, nurse practitioners, and other supports there from the virtual emergency department that's run by UHN to provide that kind of healthcare support for patients who have the highest needs and have been long neglected housing options who are also on the city list as being actively unhoused. These are patients that you know, people that you know? Yeah. I mean, I think this is where the team and, again, the University Health Network, community health workers, and social medicine navigators working really closely with Fred Victor

over the last, you know, now many months, actively engaging and working with folks to rebuild trust, as Keith mentioned, right? Like the trust piece is massive. And part of that's about the language that was being used, the frequent flyer, you know, you're taking up space, but it's also people's experiences would lead to a lack of trust in the healthcare system.

So how do you go about stitching that back together? Well, one, I think there needs to be the humility from us in the healthcare system, especially the acute care system, that we've not historically been safe spaces for a lot of people, especially marginalized groups. And part of that is the partnership piece. There's an element of where Fred Victor has such longstanding expertise and credibility in working with people who are unhoused, the partnership is really important.

A number of the different partnerships and the community engagement aspect around trying to rebuild what the role and responsibilities are of hospitals as anchor institutions in the country. But then to your point at the very frontline level, it's actually about changing the workforce, shifting the workforce with people who have a lot of lived experience and expertise. So we have community health workers and social medicine navigators who weren't here five years ago, but have been here in the past year, who having that trust and that lived and shared experience working with these folks, as well as peer workers with the neighborhood

group and the emergency department. So it's been a real shift in how we're actually staffing with physicians and nurses, people who can help push away a trauma-informed approach to push away from that stigma. What does that sound like? I mean, if you're talking to those people who have lost trust in the system and you are, you're part of the system, but you're also trying to change the system. What does that sound like when you're speaking with them? I think there's a lot of hurt. I think there's a lot.

I think Keith said it around the feeling of being shattered or this feeling of being shut out is how I would describe it. And I think there's a rightful skepticism about why and how is this going to play out. And I remember actually this through the pandemic. I remember speaking to some individuals who were unhoused, who were lining up to get the vaccine, the COVID vaccine. And I remember an individual saying to the group of us as physicians and nurses, I don't need a spiel about the vaccine. I'm going to do it. I've done my research. I'm going to get the vaccine. But where are all you going to be tomorrow when this is done? And that always stuck with me about

what is our responsibility on it. We were willing to move mountains when there was a pandemic to try to ensure people were housed from a sense of disease transmission. It's now two to three years post some of those vaccine clinics. And what is our responsibility and our moral imperative as a healthcare system to try to ensure that there's that support for people and ensure that there's a rebuild of that trust? Keith, how do you go about addressing that skepticism in the long term? I think Fred Victor has such a long history of working with people who have been living on the margins for over 130 years,

and in fact, over the past 40 years, specifically in this kind of housing. Trust needs to be regained, and it takes time. It's not like somebody who's hired as a frontline housing worker, they're plunked into a housing complex, they immediately try to do things there, but it's really sitting down with the person, getting to know them, getting to walk with them on their journey that brought them to the point that they're being housed in here, done. And if there are bumps... There's going to be steps forward and backwards. It's a matter of building up and walking with them, talking with them, engaging with them. And also the experience.

Andrew talked about lived experience. That is such a vitally important piece of our work, of our work together in this project, that we have staff who have lived experience. They may have been homeless in the past or may have had intersections with various aspects of various systems. There's a relatability. When you talk about language, there's a language that can be related there and an experience that can be shared without disrupting boundaries of course but it's if there are bumps on the road along that journey i mean one of the fears that somebody might have is that if they make a mistake they're going to be thrown back out because they may have been facing eviction exactly we're we eviction is not our first go-to, to be honest with you. A person will have bumps. We know that's going to take place in any of our housing. We will work with that person, whether it's a bump on their rent or what have you. We have rent payment plans.

Eviction is not the first step we take. If there's conflict with a neighbor or what have you, in conflict resolution how do you do that and work with the people and that starts from day one of the person well actually before day one that person moves in even before when we get to meet the new tenants coming in is explaining what this what this building is all about here are some expectations here is what you can expect from staff. And our responsibility as staff is to follow through in what we're saying we're going to do. And that's where trust is built.

It's also where trust is lost. What about trust with the broader neighborhood? How do you go about, I mean, it's not an island. Exactly. In a close-knit city, how do you build trust with the neighbors around you to say that this is something that is for all of us? Absolutely.

I think the first step that was building this trust happened a few years ago with local neighbors, neighborhood associations, and I've been in this business for a long time. I've never seen a more welcoming neighborhood. Neighbors asking, when is this going to be open? We're so excited for it. Are you surprised by that? I'm surprised by that.

I think this is an amazing testament to the neighbors around Dunn Avenue who welcomed this, who had critical questions about what kind of support is going to go on in that housing. If this is to be a solution to end homelessness in the long term, how is that going to take place? It was not the usual NIMBY story of saying, I don't want that, I don't want those people in here. They recognize that these people are their neighbors. And I think that's the first step of building trust.

And our ambition, if you will, when people are moving in, is how do we, there will be welcome committees. There are literally welcome committees in the neighborhood for people coming in, but also how for, for those tenants who are coming in, how are they going to integrate? How are they going to feel welcome in the, into the neighborhood? I think there's great potential here. What's the message? We just have a couple of minutes left.

What's the message that this project sends, not just to that community, but to the rest of the country, do you think? This is one of those issues that is, I mean, people talk about wicked problems. Homelessness dealing with a housing crisis is a wicked problem. It's a wicked, wicked problem. But, my God, look at the solution that was created in five years. So let's cut that time in half to two and a half years. Is it scalable, do you think?

I think it's scalable. Or is it at least stealable? It'll be evaluated. We know it's going to be evaluated. And anecdotally, we've been doing this work for years. I know this is going to work. It's going to stumble along. There's going to be some issues that may come up,

but they're not unsolvable. And it is scalable. Andrew, I mean, we're just about out of time, but 51 units isn't going to solve the housing crisis, but at the same time, it's more than nothing. And when you think of that parking lot that you and I talked about five years ago, when you see units now going up where people are going to move into, what does that do to you?

It gives hope that we can, as Keith mentioned, come up with solutions. But I would be remiss not to honor the fact that, Matt, we lost three people who were on the list or could have been designated for the housing who are not going to move in. They passed away. And it speaks to the mortality and morbidity facing the unhoused population. And so for me, we need to scale this and do more. Every day that we're not moving on these options and these solutions, we are losing people. And I think that is the imperative. That is the urgency that we have here. This is in no way mission accomplished.

I think this comes out, as Keith mentioned, a scalable and evidence-informed model that is cost-effective that we need to see across the country because every day we don't act. There are people that aren't even making it into the emergency department. They're passing away. It's great to talk to you both about this. This is really interesting and inspiring work. Thank you. Thank you. Thanks so much. Dr. Andrew Bazzari is Executive Director of the Gattuso Center for Social Medicine with the University Health Network. Keith Hambly is CEO of Fred Victor. It's a non-profit organization in Toronto that works with people who are unhoused.

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