Integrating Healthcare and Housing Supports in Shelters: Treating the Symptom
This post is the fifth in a series highlighting House of Friendship’s work on ShelterCare. Over 70% who seek emergency shelter in Waterloo region are navigating addiction, mental, and/or physical health challenges. Through the ShelterCare Solutions Lab, we will work together on designing solutions to better meet these needs through responsive and relationship-based healthcare and housing supports in emergency shelter. The previous post on Exploring Root Causes and Symptoms can be found here.
Intuitively, we know that treating the symptom can help in the short-term but lead to issues in the long-term. In system theory (when people study how things are interconnected), we call this type of system “shifting the burden”. When you think about it, that’s exactly what it is: shifting the problem from one part of the system to a different part. A clear example of this is the long wait times we see in the emergency department of our local hospitals. It’s a great short-term solution to so many problems, but we know it’s not a sustainable fix.
If you think about the shelter since in Waterloo Region right now, we have a bunch of models that we are experimenting with, some that have the potential to be long-term (where are often called “fundamental”) solutions, but many of which are models set up in a hurry to fix short term problems caused by the pandemic. We’re going to look at three examples identified from the emergency shelter space, review the often unintended side effect for each, and then share some possible first steps for moving forward.
24/7 Access to Private Space
In our first example, House of Friends and the staff that support the men’s emergency shelter—which has moved from the Radisson to the Waterloo Inn, then moved again from there after a fire left the building uninhabitable—have provided unprecedented 24/7 access to private space for participants. While this may solve a lot of issues related to privacy, it may also contribute to decreased engagement and a higher rate of overdose (side effects of the “symptomatic” solution). In this example, the project team thought an appropriate mix of spaces would be a fundamental/long-term solution to some of our problems. Here are some examples of steps we could take to develop an appropriate mix of spaces:
Provide common space for people to go and decompress
Identify private spaces that can be used short-term for private phone calls with family, friends, and important community services related to housing and healthcare (spaces that can still be monitored as needed)
A safe place to put belongings is one important aspect of privacy and psychological safety
Another aspect is a culture of safely built and maintained through relationships and trust
Use the instances where privacy isn’t available (having a door to close and lock) to motivate participants to engage in permanent housing conversations
We also know that privacy means a sense of safety while sleeping, and that congregate sleeping settings do not currently provide this for participants—so there are some benefits to the 24/7 access model.
De-incentivizing Shelter Stays
In our second example, the project team discussed the average length of stay we are seeing in the emergency shelter system. For obvious reasons, we want participants to stay as long as they need to in order to access permanent housing but not a day more. Part of the strategy we have traditionally used in the emergency shelter system is to de-incentivize shelter stays, including the fact that we typically only provide overnight services. However, the side effect of this can be a decrease in stability (sometimes people decide to street-sleep instead of coming back to the shelter). The fundamental solution the group discussed was ensuring participants had the ability to find permanent housing, including engaging in the conversations required to develop a plan and make it happen. Here’s what that might look like:
Use the shelter experience to build the participant’s trust in the system, leverage the relationships they build here to smoothly transition support
A particular focus should be on rebuilding the trust and relationships they have with medical care staff, connecting with outreach staff instead of the emergency department
Provide enough healthcare service to ensure the level of stability required for participants to consistently engage in housing conversations
This led to a longer conversation around what exactly healthcare in the emergency shelter system means for participants short-team vs long-term, so we decided to make that the third example.
Bringing Care into Shelter
The final example of shifting the burden has to do with the participants that enter the emergency shelter system, who are not in good health. Currently, we are exploring what bringing care directly into the shelter means for participants. While we are seeing many benefits, we acknowledge that a potential side effect is the dependency on shelter services that participants might develop. The ultimate goal/fundamental solution is access to and sustained engagement in mainstream services for all participants. Here are some things we should keep in mind as we move forward:
More dialogue with healthcare funders, since the health of this population shouldn’t just rely on the housing sector
Identify which interventions are necessary during their shelter experience, focusing on those that will support them to move forward
Develop a way to do warm handoffs as they transition to permanent housing, including a coordinated plan or case management
We have evidence from the first six months of the pandemic that suggests this much of this population is not getting the level of care they need to get permanently housed. There exists today a gap between outreach services and mainstream services (funded by the LHIN). No one wants participants to step down from their shelter experience into permanent housing—it has to be a step up.
Next steps
Highlighted here are three examples of short-term solutions that respond to problems we see in the emergency shelter system. However, we have also included a few examples of how we can adapt these solutions, and our behaviour, to move toward long-term “fundamental” solutions like an appropriate mix of spaces, ability to find permanent housing, and access to and sustained engagement in mainstream services related to healthcare. As part of the Solutions Lab work, our next steps will focus on developing ideas and prototypes for improving the experience of participants as they move through emergency shelter into permanent housing.
Get Involved
Do you have suggestions for our problem tree?
Can you see something that is missing or needs to be updated?
Check out the ShelterCare website for more information and how to connect with Sarah Brown and the Solutions Lab team.
As a Solutions Lab Provider, Overlap Associates partners with organizations to work through complex housing issues and scale potential solutions. A Solutions Lab is a collaborate initiative to solve complex housing problems using innovative methods and tools. For the organizations participating, a Lab is an opportunity to develop innovative solutions to a complex housing problem, as well as build capabilities for design, collaboration and problem-solving. Learn more about our Housing Solutions Labs here.
