I have worked in health care for more than 30 years as a professor, researcher and hospital executive. For the last half-century, intellectuals, doctors and policy leaders in Canada have engaged in countless conversations about the social determinants of health: the idea that basic needs like housing, food security and income are just as integral to a healthy society as an effective hospital system.
We’ve had a strong understanding of that since at least 1974, when Marc Lalonde, the minister of national health and welfare under Pierre Trudeau, released A New Perspective on the Health of Canadians, a seminal academic work that defined those social determinants and their importance in maintaining a healthy population. And yet very few hospitals in the country—and the world, for that matter—have stepped up, moved beyond rhetoric, and focused on creating those conditions for patients. Instead, we wait until people are sick to improve their health.
It’s estimated that more than 235,000 people in Canada experience homelessness every year. This increases the likelihood of negative health outcomes like infectious diseases, substance abuse disorders and injuries. Many of these folks have no family doctor, so they have no choice but to visit crowded emergency rooms. At University Health Network, we have roughly 230 frequent visitors (most of whom are unhoused) consuming 15,000 emergency room visits per year—that is more than one visit per week, each—not because of a medical emergency, but because they have nowhere else to go.
We are a few months away from changing that. In August 2019, UHN entered an agreement with the city of Toronto, the federal and provincial governments, and the United Way to build Toronto’s first community of supportive housing units dedicated to frequent users of the health care system: 51 modular residences all built on UHN land at 150 Dunn Avenue in Toronto’s Parkdale neighbourhood. Our clinicians will be able to prescribe housing to patients who are unhoused or living in precarious homes, in the late stages of sickness, dealing with extreme poverty or struggling with mental health and addiction disorders.
The modular apartments, made of steel and Douglas fir, are designed and built off-site by NRB Modular Solutions, and then transported to the lot for assembly. This speeds up the building process and limits greenhouse gas emissions. The 51 units, all contained in the four-storey condo building, were conceived as efficiency pads: they are modular, identical 275-square-foot studios with galley kitchens, a living room, a bedroom and a bathroom. We designed the units after consulting with people who frequently visited our emergency rooms to understand their preferences in a living space. The majority wanted lockable doors, a personal shower (rather than shared bath facilities) and a pet-friendly building. Each floor will also have a larger communal kitchen and living room accessible to all residents, as well as meeting rooms and staff offices for health-care professionals or support workers.
We plan to employ community support workers and helpers who are familiar with the struggles of the residents. These workers could help residents connect with family doctors and other social services, such as addiction support, social work, counselling and therapy. Residents will be expected to pay a small amount of rent based on what they can afford to help cover maintenance costs of the building, which will be about $400,000 a year. We expect that several of the residents will be on ODSP, and they can use that funding to help them make the rental payments. We’re not putting a limit on how long someone can live in the units, because evidence from around the world shows that short-term solutions (like 30 days in a house) are not enough to put someone back on track. Our ultimate goal is to help our residents become healthy enough to move out and back into the world.
Right now, we’re limited to a modest number of units, and we’ll soon face the dilemma of deciding which patients would benefit the most and how to ethically allocate them. Our ethicists and clinicians have developed a rigorous method of evaluating patients, and priority will be given to people on the city’s subsidized-housing wait-list (which currently comprises more than 80,000 households), who often end up in Toronto’s emergency departments and hospital re-admissions. Our clinicians are also asking people they often see in their emergency rooms about their housing situations, economic circumstances and food security; if we frequently see a particular patient in our system, a clinician can work with a community support worker to decide if they could benefit from prescribed housing.
Those decisions are incredibly difficult, and I worry that the residences will fill up quickly. The good news is that this project is scalable; we can construct a building like this one in three to six months. Our dream with our partners includes creating more than 500 homes like these across the city, and if these units prove helpful in improving the health of their residents and relieving our emergency rooms, we’ll consider building more around this Parkdale campus. We’re also entertaining the possibility of leveraging existing buildings to create more units.
I’m already very proud of this initiative. UHN is the country’s largest hospital and research system, and is known for providing tertiary care for really serious medical situations like heart and lung transplants, rare cancers and complex neurosurgical procedures. But we are also the best endowed hospital, and felt we had to create the continuum of care that our community needs right now, and housing is a huge part of that. This is no small venture.
Soon, Toronto will be one of the first cities in the world to have health-care-based housing. Vienna and San Francisco have launched similar programs, and already have remarkable examples of success. That mirrors academic evidence showing that housing-first interventions tend to have much better outcomes for homeless adults who suffer from mental illness than treatment as usual. Our next step is to welcome patients, learn about their lived experience in the units and iterate accordingly. If we notice their health is improving, and we see a decreased burden on our emergency rooms at the same time, we’ll call this a success.
—As told to Alex Cyr