The largest academic hospital in Canada is planning to offer a radical new treatment for its neediest patients: a place to live.
The University Health Network (UHN) in downtown Toronto has committed a plot of land worth nearly $10-million to a unique affordable-housing project designed to ease overcrowding at the network’s two acute-care hospitals.
Last month, the UHN signed a memorandum of understanding with the City of Toronto and the United Way Greater Toronto to launch what they are calling a “social-medicine initiative.”
The linchpin of the plan is a proposed affordable-housing development on a 30,000-square-foot lot the UHN owns in Parkdale, a rapidly gentrifying neighbourhood where sky-high rents are forcing the poor out of stable housing and, in some cases, into the emergency room.
“Never in the country has there been a hospital willing to rededicate land to housing, which we know is inextricably linked to health,” said Andrew Boozary, the UHN’s executive director of health and social policy and a family doctor. “This is one of the major pressing issues in the city. For us, it’s one of the major public-health issues.”
The social-housing portion of the initiative is a long way from breaking ground.
All three partner agencies say they’ll first work with the community to decide what type of housing and other social supports are best for the site, which is currently a large parking lot next to the Bickle Centre, a long-term care home owned by Toronto Rehab, one of the UHN’s four hospitals. And the affordable units, whenever they open, are unlikely to be reserved exclusively for UHN patients.
But the plan’s backers say the UHN’s land contribution speaks volumes about a growing understanding that if patients can’t afford fresh food, quality child care and a decent place to live, they’re more likely to wind up in the hospital, particularly if they also struggle with mental illness and drug or alcohol addiction.
“If you can’t take care of your diabetes because food choices are difficult and stresses are there, what do you do about that?” said Manjit Jheeta, interim director of the Toronto Office of Partnerships. “You go to a doctor or you go to a hospital.”
UHN president Kevin Smith said the hospitals he oversees are – as with many hospitals in Ontario – already at a breaking point when it comes to waiting times in the emergency department and overcrowding elsewhere in the hospital. (Along with Toronto Rehab, the UHN includes the Princess Margaret Cancer Centre and two acute-care sites, Toronto Western Hospital and Toronto General Hospital.)
The Ontario Hospital Association recently reported the worst June since 2008 for emergency-department backlogs, with patients who needed to be admitted to the hospital waiting an average of 16 hours for a bed.
Although a complicated mix of factors is to blame for what Ontario Premier Doug Ford calls “hallway medicine,” finding homes for poverty-stricken patients who no longer need acute-care beds could help, as could keeping high-needs patients out of the emergency department in the first place.
In 2018-19, there were 61 patients from midwest Toronto – an area that includes Parkdale – who visited the emergency departments at Toronto General or Toronto Western 20 times or more. They accounted for 2,096 visits, or an average of 34 visits each.
Patients who go to the emergency room every 11 days, on average, are more likely to need a social worker than a doctor.
“We have to do things differently,” Dr. Smith said. “We know that emergency rooms are the wrong place to serve these clients well.”
With plans for the affordable-housing project still in their infancy, the UHN, the city and the United Way in the meantime plan to undertake social-needs screening in the Toronto Western and Toronto General emergency departments in hopes of connecting struggling patients with existing programs.
The three partners are also talking with the Dalla Lana School of Public Health at the University of Toronto about having researchers meticulously track the outcomes of the social-medicine initiative, Dr. Boozary said.
The hope, he said, is that Toronto’s initiative will be as effective as Housing for Health, a Los Angeles County Department of Health program that identified frequent users of health-care services, most of them homeless and chronically ill, and moved them into supportive housing.
Rand Corp., a non-profit policy think tank, tracked nearly 900 participants in the L.A. program and found their use of public health-care services dropped dramatically once they had a roof over their heads. For every dollar L.A. County invested in the program, it recouped $1.20.
Sarah Hunter, the senior behavioural scientist who oversaw Rand’s evaluation of the Housing for Health program, said those results need to be taken with a grain of salt, especially if the UHN and its partners expect their initiative will save money.
“If you look at the field over all and if you look at more rigorous studies like randomized control trials, they have not observed these dramatic reductions in cost,” she said.
Much depends on the intensity and quality of the support for participants, Dr. Hunter added.
Leaders in community health have long recognized how hard it is for patients to stay healthy if they’re homeless or couch surfing, said Kate Mulligan, director of policy and communications for the Alliance for Healthier Communities, which represents community-governed primary-care clinics across Ontario.
Some community health centres are already deeply intertwined with affordable-housing projects. For example, Ottawa Community Housing opened a 42-unit seniors’ residence atop the Carlington Community Health Centre this year.
But this is a first for a Canadian hospital, said Dr. Mulligan, who is also an assistant professor at the Dalla Lana School of Public Health.
“It’s important materially and symbolically," she said. “We literally need community housing here in Toronto and the symbolism of Canada’s biggest hospital investing in housing is also very important.”