Re: Jenkinson et al., “Nowhere to go: exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto, Canada”

Abstract

I read with interest the article by Jenkinson et al. published in the Canadian Journal of Public Health (Jenkinson et al., 2021). I commend the authors for their careful study of the context in which hospital workers attempt to discharge patients experiencing homelessness. The authors rightly call for research “that includes the voices of people experiencing homelessness who go through the discharge process.” Work recently undertaken by our group may prove illuminating. We conducted a qualitative study of individuals with heart failure (HF) experiencing homelessness in a single US city, examining participants’ interactions with the healthcare system (Pendyal et al., 2021). In the United States, HF is the leading cause of readmission within 30 days of an index hospitalization; hospitals with high readmission rates incur financial penalties (Eapen et al., 2015). We believe this makes HF, which affects millions of individuals, particularly relevant when studying the increasingly metric-driven economic environment in which, as Jenkinson et al. note, hospital workers operate—as well as the difficulties faced by vulnerable patients within this system. At the individual level, we found that stigmatization by hospital workers influenced participants’ experiences. This stigma manifested in the discharge process. As one participant noted, hospital workers emphasized that the hospital is “not a hotel,” and that he should not “think [he’s] gonna live here.” This participant became accustomed to being treated and sent “back to the street,” echoing a statement made by a hospital worker in Jenkinson et al.’s study that for “patients who come in frequently...there isn’t the same patience once they’ve been in a few times”—largely due to efficiency pressures imposed on staff. This concept of stigma, we believe, warrants further attention in the context of homelessness, as efforts to counter stigma and broaden hospital workers’ structural competency (Metzl and Hansen, 2014) may make them more apt to, as Jenkinson et al. write, “[push] back against managerial pressures” in order to find a safe discharge destination. There are also, of course, systems-level factors undergirding the conjoined crises of homelessness and inequitable healthcare. Jenkinson et al. astutely point to neoliberal policies that have been adopted in Canada; similar policies have been enacted in the USA. HOPE VI, for example, dismantled public housing and displaced thousands of persons, with far-reaching health consequences (Keene and Geronimus, 2011). Any discussion of homelessness and health must therefore address its central feature: a lack of affordable housing. In addition to advocating for more affordable housing, however, our work also highlights a more proximate goal: the creation of medical respite (MR) programs. Jenkinson et al. correctly note that many MR programs have stringent exclusion criteria, which we believe only underscores the need for their expansion. In our study, participants who had been hospitalized for HF and discharged to MR were able to regain a sense of stability, form routines, and experience freedom from tradeoffs. In one participant’s words, MR “got me doing it right...making all my appointments...doing the medication, eating right...feeling great.” I again congratulate the authors for their insightful and original work. One of their study’s key messages, that “a human rights approach to housing must be employed to navigate improvements in the hospital discharge process,” is one that we in the USA would do well to heed. * Akshay Pendyal [email protected]