This article is part of a series exploring the concept of population health, with the goal of considering the role of a hospital in improving population health. The series features successful initiatives of health systems that have invested beyond their walls to improve the health of their communities. To visit the population health resource page and view the rest of the articles in the series, click here.
The number of patients waiting in hospitals for a more appropriate care setting has been a long-standing challenge that demands creative solutions addressing non-medical factors influencing health. Because the chain of health extends beyond hospitals, it's vital to take a population health perspective that considers patients' broader determinants of health.
Being forced to wait in hospital for more appropriate care diminishes patients' quality of life. In fact, a number of these patients, designated alternative level of care (ALC), have been waiting for over a year in mental health beds due to a lack of supervised or assisted living options. This has also created a significant bottleneck in the system, blocks access for other patients requiring hospital care, and is the most expensive care option.
By taking a population health approach, a partnership between Indwell, St. Joseph's Health Care, London (St. Joseph's London) and multiple partners across western Ontario, is having a very positive impact on this long-standing issue and setting an inspiring example for others. Most importantly, it's given many patients a new start in life and a real chance at long-term recovery.
Indwell is a not-for-profit housing developer and supportive housing provider who
se mission is “Hope and Homes". Their values align with housing-first principles, and they believe in high-quality, supported and deeply affordable housing that's focused on supporting tenants to help build better communities. By addressing the social determinants of health (SDH), such as housing and employment, individuals with serious and persistent mental health and addiction issues can progress in their journey to recovery.
For Indwell, affordable housing is more than building a physical space, it must include the development of health infrastructure and a focus on creating a supportive community that will enable tenants to live independently. In fact, Indwell serves as the health service provider with the help of partnerships across the system. Tenants receive a host of supportive services, such as primary care, mental health and addictions treatment, and other social supports. The buildings are also intentionally designed to invite the community in. For example, co-located businesses offer employment opportunities to tenants which, in turn, helps individuals integrate into the community and become active members.
“When you have a network around you, are happy where you are, feel safe where you live and supported, that manages a lot of the distress that drives people into homelessness and emergency departments," said Jodi Younger, Vice President, Patient Care and Quality, St. Joseph's, London.
London's affordable housing crisis has been a long-term issue that's significantly impacted hospital patients. When Younger joined St. Joseph's, London five years ago, 52 per cent of tertiary beds were occupied by individuals who had been in hospital for more than a year because the hospital would not discharge them with no place to go. Until Indwell came into the picture, there was nowhere to send patients who required more than safe, affordable housing or a physical address to call home.
The Burning Platform
Broader implementation across the province is a goal that Indwell – along with its partners and supporters – is striving for. The key to gaining widespread support lies in re-framing the issue so that it's not focused solely on hospital challenges, such as ALC, but seen as a collective priority for communities.
“In London, the idea of 'homeless in hospital' opened the conversation and helped illustrate the why for the municipal government to consider a creative solution," said Younger. “Today, Indwell has a lot of support in the community because it's a model that people now understand."
Indwell approaches municipal leaders, such as those in St. Thomas, to ask about their major concerns within their communities and where Indwell can have the most impact.
“In St. Thomas, they told us that their main concern was supportive housing," said Steven Rolfe, Director of Health Partnerships at Indwell. “They estimated that about 150 units with a range of supports would go a long way in eliminating street homelessness, the backlog in shelters and hospitals."
Indwell went on to develop Railway City Lofts in St. Thomas (pictured on the right), specialized supportive housing for shelter-less individuals. It's been a great success and Indwell is now in the process of constructing two more sites in St. Thomas. This includes the old fire hall on Queen Street where they are hoping to integrate several existing programs and transition people from congregate living spaces to more independent housing with supervision and supports.
“When you have intentional investment in health infrastructure in the community – not just housing, but support pieces that go alongside it, not only do you enable hospitals to do what they're designed to do – acute care – you also allow people to receive the most appropriate care in the community instead of ending up in EDs," said Younger.
Railway City Lofts: St. Thomas
Railway City Lofts is a specialized supportive housing initiative that opened in October 2021. It emerged from a number of positive partnerships, including with St. Joseph's, London, the municipality in St. Thomas, and St. Thomas Elgin General Hospital.
At the time, the municipality wanted to tackle the issue of homelessness and had a building that was available. The partners came together to develop an advanced proposal that hadn't been done before. Rather than focusing the proposal on the ALC problem, it was based on the population being served: people with chronic conditions, high acuity and profound histories of housing instability.
When the program opened, Indwell worked with all its partners around referrals, with the most appropriate individuals being those who were shelter-less (shelter-restricted and living in encampments). They invited 15 people into their own homes, a majority of whom remain three months later. Railway City Lofts is treated as permanent housing, with tenants living under an occupancy agreement, but the future goal is to move them to more independent housing with supports.
So far, the data is very promising. Police have seen an 80 per cent reduction in police calls in the downtown core after opening the program.
Clients receive services from a team on-site, such as nursing, addictions, housing and behavioural supports. By working with primary care and specialized hospital care providers, tenants all have access to addiction treatment and primary care. A partnership with St. Joseph's, London also enables the on-site team to reach out for consultation, training and collaboration, while a partnership with the Canadian Mental Health Association provides access to intake, development and programming.
The partnership between Indwell and St. Joseph's, London has caught the attention of health planners at Ontario Health and the Ministry of Health because of its significant impact on the healthcare system.
"It's not just about how to get people out of hospital but how to keep people with chronic conditions continuing on their recovery journey in the community," said Rolfe. “Integrated Decision Support* helped us understand the impact of integrated healthcare in housing across our programs by allowing us to run a sample in three programs which showed a 50 per cent reduction in ED use across an 18-month pre- and post-admission to housing condition."
“Living at Railway City Lofts has given me stability and hope. It's made me want to wake up every day. Having the staff here, knowing that they're truly good people and here for my best interests, is really good. For a while, I didn't know who to trust, but I know I can trust the staff who have given me a safe space to be myself.
Before Indwell, I was living in shelters and camping in the forest. It wasn't easy finding food – some days were better than others. My items would get stolen, and sometimes I didn't feel safe. When I heard I was up for an apartment at RCL, I didn't want to get my hopes up. When I first moved in, it felt really weird. I couldn't sleep inside, so I slept on a bench across the street. But now I feel very comfortable sleeping here. I love that I can get the space I need, lock my door, and keep my items safe. Staff are here for me and always have their doors open. I've started medication that is helping me, and I'm in a space where I can be at home."
- David Smith, a tenant at Railway City Lofts
How Hospitals Can Help
Hospitals can play a number of critical roles in helping to move this model forward.
It's clear that mental health and addictions services require more investment, coupled with accountability to ensure the most efficient and effective use of dollars. In this respect, specialty hospitals have historically been linked to housing, but they really shouldn't be in this business. There are incredible, creative not-for-profit partners and this is their expertise. With this in mind, St. Joseph's, London is currently looking to identify financial resources that may still be aligned to historic housing models and will recommend that government direct these resources to Indwell's supportive housing units. It simply costs hospitals more to operate a supportive bed compared to a not-for-profit.
Hospitals are also well-positioned to use their political influence to help raise awareness about these issues, both with provincial and local governments and with the community. In London, St. Joseph's helped use their relationships and reputation within the community to open up the conversation about people being “homeless in hospital". This shifted the city's previous approach to the development of affordable housing units, and it has paid dividends, especially in the lives of people like David Smith.
“Indwell is now a high-profile partner in London with lots of support from the community," said Rolfe.
At times, taking a leadership role means stepping back to allow others to be at the helm by being collaborative partners in the community and working differently. Hospitals can help advocate for and encourage capacity building in the community to support people who need this kind of service. They can also share their knowledge and expertise with partners.
“Hopefully with the evolution of the OHTs [Ontario Health Teams], we really begin to collaboratively discuss health spending and health planning from the client journey perspective," said Younger. “If we continue to compete for resources, the biggest, most established parties will continue to win – so how do you build equity into the conversation? That should be the fifth quality indicator – achieving equity."
A critical part of rebuilding the healthcare system in the aftermath of the pandemic is integrated development which includes robust community services and building services around where people live. Recovery should not be hospital-dependent but be informed by those receiving care.
*To learn more about the OHA-stewarded Integrated Decision Support (IDS) platform, please visit the OHA's Data and Analytics website.