By Kristina Marie Kokorelias
“Wash your hands regularly.” “Complete these exercises at home.” “Take this medication with food.” “Install a grab bar in the shower.” Sounds easy, right? Not for Toronto’s homeless community.
It is hard not to notice the growing presence of persons experiencing homelessness on the streets of Toronto and other areas in Canada. Amid the current coronavirus (COVID-19) pandemic, the number of homeless encampments in the city has seemingly doubled (1). Afterall, the crowded shelters, considered a safe space for homeless people during normal circumstances, suddenly pose a risk of transmission of the virus. According to Adi Rittenberg, an occupational therapist working in mental health:
“People experiencing homelessness already face an overwhelming amount of stigma while navigating the community. The current hypervigilance to hygiene, increased isolation, and physical distancing measures have dramatically compounded this reality.”
While it is difficult to determine the exact number of homeless persons, or those facing unstable housing, there are some important indicators suggesting homelessness is a growing concern for rehabilitation professionals (e.g., number of people accessing shelters and drop-in centres). Haven Toronto is one example of a drop-in centre for homeless individuals that has experienced an increase in the number of clients they are assisting. Lauro Monterio, the Executive Director of Haven Toronto shared with rehabINK that:
“Since the start of the Pandemic Haven Toronto has seen a 260% increase in people accessing our services, while at the same time that we were forced to alter our services and restrict the access, as have all of the providers of community services in the downtown.”
Clinicians must also consider the older adult population in their work. Monterio stresses that:
“Older adults who are homeless have a mortality rate that is three to four times greater than the general population. They often require access to specialized medical care beyond what is available in shelters.”
The statistics support such claims. Garibaldi et al. (2) found that those over 50 were 3.6 times more likely than younger homeless people to suffer from a chronic medical problem. Clinicians and rehabilitation scientists are urged to seek a better understanding of the intersecting needs of homeless older adults who are at a high risk of contracting COVID-19. To do this, a better understanding of homeless persons’ narratives are needed to help identify rehabilitation needs.
Many COVID-19 survivors will need rehabilitation. Patients experiencing homelessness suffer from the same complications of the virus as those who are not homeless. However, helping patients experiencing homelessness and COVID-19 access healthcare and re-integrate into the community is more difficult. According to Monterio:
“The complexity of mental and physical health conditions that older homeless people experience, combined with shelters, drop-ins and respite sites that often inaccessible and/or ill-equipped to meet older people’s needs are a major barrier.”
“The complexity of mental and physical health conditions that older homeless people experience, combined with shelters, drop-ins and respite sites that often inaccessible and/or ill-equipped to meet older people’s needs are a major barrier.”- Lauro Monterio, Executive Director of Haven Toronto
COVID-19 has changed the way we look at our homes. Across the country, people are being told to stay home as a way to slow the spread of COVID-19. For those without a stable home, there is no home to stay in. The challenge of finding secure housing is compounded when someone has the virus and trying to stop the spread.
“Recognizing the disproportionate impact COVID-19 has on the homeless community is critical in providing client-centered, equitable, and sustainable community reintegration” says Rittenberg. People who are homeless have a unique set of healthcare needs, many of which are unrecognized or untreated in rehabilitation healthcare settings (3,4). Beyond having a stable home, people who are homeless face barriers including sleep deprivation, unsafe living conditions and lack of transportation. The COVID-19 pandemic’s unprecedented shift to virtual interactions with healthcare providers also means that a large number of homeless individuals are unable to participate in receiving care. Many individuals with limited financial resources often cannot afford devices or the associated internet service fees and with many public centres closed, the ability to communicate via the internet is limited. Throughout the interview with Rittenberg it became clear that there is a lack of understanding of the needs of individuals experiencing homelessness in healthcare.
Rehabilitation clinicians must be cognizant of the realities of homeless individuals in order to assist them in meeting their unique needs. For example, discharging homeless patients to the streets after in-person rehabilitation care must also be considered. According to Rittenberg:
“Not only does this practice place unjust ownership on the individual to overcome significant systematic barriers, and most often worsens health outcomes, it also drives up costs and inefficiencies within the public sector.”
The COVID-19 epidemic is an unprecedented disruption to healthcare systems worldwide. There are concerns about where to best provide care for individuals with COVID-19, with most suggestions stating that individuals stay at home as asymptomatic people will unknowingly spread the virus. The possibility of asymptomatic spread has implications for those in congregate settings, such as homeless shelters, who are unable to abide by infection-control practices (e.g., social distancing, self-isolation). As a result, those with COVID-19 who are in precarious housing must remain in costly in-patient settings. The lack of alternative rehabilitation care sites for the isolation and quarantine of people who are homeless is of growing concern to experts like Rittenberg.
A lack of education about various housing statuses is not helping clinicians. As a minimum, clinical rehabilitation teams must ask about patients’ housing statuses. To do so, clinicians need to ask these questions as soon as possible in the rehabilitation process to makes sure needs can be met. Therefore, the rehabilitation care system must allow for ample time for patients to tell clinicians about their situations. A warm and empathic approach can go far. Allowing the time and space to build a trusting relationship between the patient and clinician can help clinicians best develop a discharge plan that fits with the realities of daily life for people experiencing homelessness (e.g., precarious housing situations, inabilities to safely complete physical exercises). Working with social work teams can help rehabilitation clinicians maintain an updated list of services available to support homeless individuals and can help solidify plans for accessing services into place before discharge.
Rehabilitation care for homeless patients must also consider the utilization of preventive and follow-up care to avoid readmission to rehabilitation. Ensuring education and follow-up care plans are in a language that the individual can understand and seem reasonable to the individual is vital. Clinicians should discuss potential follow-up barriers (e.g., financial, transportation, geographical) with the patient. Rehabilitation clinicians are urged to spend time on health education and promotion prior to discharge. Rehabilitation professionals and other health and social care providers should share resources to help support recovery processes outside of healthcare settings, such as at homeless shelters. Community rehabilitation programs at homeless shelters, drop-in centres and food banks can help patients connect with care.
Beyond physical health concerns, rehabilitation clinicians should encourage supporting meaningful occupations (e.g., volunteering, participating in hobbies) for homeless individuals. Especially when many drop-in centres and shelters are running at a reduced capacity during the pandemic, homeless individuals may often be deprived from occupational engagement, which can have detrimental effects on their health and well-being. Sam*, a volunteer at a various homeless drop-in centres and shelters raises concern over the lack of social support available for homeless individuals during the pandemic:
“Since there are no longer volunteers like me coming in and out to organize activities or simply converse, I worry these people are filling their empty hours with inconsequential activities instead. That has to have an impact on their mental health.”
Homeless individuals often have vocational skills, tenacity and talents that may go unnoticed. Rehabilitation professionals are encouraged to leverage the strengths of their patients and tailor rehabilitation based on their strengths and interests. Rehabilitation clinicians can assist homeless individuals in finding activities that are suitable for their functional abilities by liaising with social services. In particular, occupational therapists can have a greater role in developing community programs to support the meaningful occupational of homeless individuals.
Educators in rehabilitation professional programs are encouraged to introduce a greater emphasis on homelessness into their educational content. As the rehabilitation profession goes forward, it is important to ensure that trainees are well equipped to work with individuals who are homeless. An enhanced curriculum (e.g., explicit training on different housing statuses, increased knowledge about the unique needs of individuals’ experiencing homelessness) may influence trainees’ attitudes towards homelessness and other vulnerable populations. Increasing education on the unique needs of homeless individuals and how to best support them can help the next generation of clinicians to take on the challenge of providing care to clientele who are homeless.
Rehabilitation researchers are also called to action. Whether conducted by academics, hospital or community-based researchers, or clinician-scientists, research should be conducted to help enable rehabilitation professionals to better understand the complexity of issues relating to homelessness in the context of rehabilitation. Topics for future rehabilitation research may include personal hygiene, access to rehabilitation professionals and explorations of social and physical environments for diverse individuals. This information may better inform strategies for caring for individuals experiencing homeless across the healthcare system. Quality research reflecting the lived realities of people existing homelessness can inform policy and service delivery.
Unlike COVID-19, homelessness is not a disease. However, like COVID-19, both have great implications for rehabilitation professionals. There is a clear and pertinent role for rehabilitation professionals to care for those who are homeless. As Rittenberg urges, “COVID-19 has emphasized the importance of ensuring our care identifies housing as an integral aspect of a rehabilitative approach, and it is critical our support addresses these complexities as we support the health and well-being of this population.”
* Pseudonym used as per request.
Featured illustration by Aimy Wang for rehabINK.
To refer to this article, it can be cited as:
Kokorelias KM. Treatment not as usual: Caring for rehabilitation patients who are homeless. rehabINK. 2021:10. Available from: https://rehabinkmag.com
- Falvo N. Homelessness, program responses, and an assessment of Toronto’s Streets to Homes program. Canadian Policy Research Networks Incorporated and Social Housing Services Corporation; 2009 Feb.
- Garibaldi B, Conde‐Martel A, O’toole TP. Self‐reported comorbidities, perceived needs, and sources for usual care for older and younger homeless adults. Journal of general internal medicine. 2005 Aug;20(8):726-30.
- Griner KR. Helping the homeless: An occupational therapy perspective. Occupational Therapy in Mental Health. 2006 Apr 13;22(1):49-61.
- Canham SL, Custodio K, Mauboules C, Good C, Bosma H. Health and psychosocial needs of older adults who are experiencing homelessness following hospital discharge. The Gerontologist. 2020 May 15;60(4):715-24.