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Integrated Health Services for Women Who Are Homeless and At Risk of Homelessness: The Situation in Ontario

I Introduction

The incidence of homelessness is rapidly increasing across Canada. While popular images of homelessness continue to focus on older men with mental illness and/or addictions issues, the proportion of women without secure, affordable shelter continues to rise. What kind of practices are being undertaken across Ontario in order to improve health services for this diverse and vulnerable group of women? What kinds of "good practice" can be identified?

II Background

The Ontario Women's Health Council (OWHC) was established in 1998 by a Conservative provincial government to "advise the Minister of Health and Long-Term Care advocate for improvements to women's health care in Ontario; promote, influence, and disseminate research on women's health issues; and to reach out and empower women across the province to make informed decisions that will contribute to improvements in their health" ( In consultations with health-care providers across the province, the OWHC heard that increasing poverty was a key determinant of women's health. The OWHC commissioned a research study on the health issues of women who are homeless and at risk of homelessness and also held a one-day think tank with health-care workers in November 2001. At the think tank, the importance of providing integrated health care for women who are homeless or at risk of homelessness was a major theme. The OWHC responded by hiring St. Michael's Hospital Inner City Health Unit, in conjunction with Oriole Research and Design, to research promising practices in integrating the delivery of health services with other services delivered to women who are homeless or at risk of homelessness.

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III Process

The research team started with a literature review (emphasizing Canadian sources) on integrating health care and other services for socially isolated women who are poor and persons who are homeless or at risk of homelessness. Consultation with experts and practitioners in the health, social services and social housing sectors in Ontario uncovered examples of agencies who are delivering integrated services for homeless persons.

This snowball survey led to contacts within over 100 agencies that are working with homeless or at-risk populations in Ontario. Particular attention was paid to initiatives that integrate health services with other services, as well as those that specifically address the needs of women. Consultation focused on urban, suburban, small town, rural and remote parts of the province. In addition to the literature review and professional consultations, focus groups were held in Toronto, Oshawa, Kingston and Haliburton to gather input on the desired elements of integrated health services from women who have experienced homelessness or are at risk of homelessness.

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IV Findings

Participants in the focus groups noted a wide range of mental and physical health problems that accompanied their homelessness, including depression, stress, anger, panic attacks, tendency to self-blame, inability to eat or sleep well, ulcers, indigestion, headaches and weakened immune system. Some women said it was hard to maintain a comfortable level of personal hygiene. Some experienced increased threats and incidents of violence. These experiences of health and homelessness are consistent with the literature-review findings and reinforce the need to see mental, physical, emotional and spiritual health issues as closely linked.

Women in the focus groups outside Toronto spoke of trying to keep others from knowing about their homelessness in order to protect themselves and their children from being stigmatized. These women found it hard to seek help. Women in rural areas face barriers that are different from their urban counterparts because there are few or no services in some towns and counties. For women in all areas, transportation, lack of money, childcare issues, health status, addictions issues and many other factors, including stigma, can make it difficult or impossible to access the services they need.

Across Ontario, a "ring model" is emerging, whereby the central city has relatively good inter-agency coordination but inner suburbs, especially in Toronto, are seeing increases in demand for services without appropriate funding and coordination. Similar pressures are likely being felt in smaller cities, suburban communities in the Greater Toronto Area and rural settings.

Of the 100 initial contacts, 35 initiatives or agencies were selected for more in-depth study. Twenty-five are agencies that provide direct services to homeless women. Many of these also count women at risk of homelessness among the clients they serve. Four housing organizations were profiled to draw attention to how services and programming can support tenants who are at high risk of losing their housing or who were formerly homeless. Finally, three inter-agency networks that do not provide direct service to homeless or at-risk clients but do focus on identifying and responding to system-wide or sector needs were profiled.

The literature review provided three different ways to think about service integration and coordination:

1. Interagency Coordination, which can result in coalitions or multi-agency staff teams delivering services or information systems to manage information between agencies for better coordination of client care

2. Co-location or a Service Hub, where a variety of services are delivered at one site or in close proximity to one another. Numerous agencies may be involved in delivering services at any one site where homeless people live or congregate

3. Case Management Approach, which relies on a case worker assigned to a particular individual to facilitate access to a full range of services and supports. The case manager may, for example, provide informal counselling, assist the client to identify goals and service needs, assist with transportation, provide information and referrals to other agencies and assist in finding or maintaining housing

Site-specific programs can be effective in connecting with women at specific points in their homelessness experience. They may, however, be weaker at providing continuity of service across time and space as homeless and at risk women lead relatively unstable lives. Looking at the experience of evolving programs at the Oshawa Community Health Centre as an example, it appears that one way to increase the long-term relationship a woman has with a health-related service, even after she is stably housed, is to keep the definition of health service broadly defined and to tailor programs to meet the continually changing and evolving needs of participants.

Particular gaps in services for homeless and at-risk individuals include

* Primary health care--community health centers (CHCs) operating at capacity, rural women travelling far from their home communities for health services for themselves and their children and a shortage of family doctors across the province all point to the need for more accessible primary health-care services for homeless and at-risk populations. Primary health care for much of the homeless population is currently provided at a number of CHCs. The current CHC infrastructure is not likely to meet this need over the long term.

* Case management services without long waiting lists--in urban areas, additional capacity is needed to meet the growing demand. In rural areas, the issue is even more basic: women need to be able to access such services for short, medium or long term assistance.

* Emotional and mental health counselling services--clients and service providers both express a need for counselling services that are not "psychiatric" in nature (i.e., based on a medical model centred on the diagnosis and pharmacological treatment of psychiatric illness). Clients need timely access to the services they require without long waiting lists. This includes mental-health counselling for children who, for example, are escaping an abusive father or adjusting to issues of impoverishment and emotional loss following their parents' relationship breakdown.

* Dental care that is free and available to homeless and at-risk women--this service is equally needed in urban, suburban and rural parts of the province. Only a few services contacted as part of this study reported that they were able of offer it in a limited way or were planning to offer it.

* Free or inexpensive prescription drugs--this issue is especially important for the working poor, regardless of where a woman lives in the province.

* Substance abuse treatment services--homeless and at-risk women from across the province need to be able to access treatment services that are sensitive to their needs. Increased services for women with both substance-abuse and mental-health problems are needed across the province.

* "Wrap-around" services that follow women as they move from unstable housing or shelters into transitional or permanent housing--while programs such as Hostels to Homes exist, the need is greater than the available services can meet. This is a need that is felt in urban, suburban and small town as well as rural parts of the province.

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V Obtaining the Report

The full report, entitled Models and Practices in Service Integration and Coordination for Women who are Homeless or At-Risk of Homelessness: An Inventory of Initiatives will be available shortly from the Ontario Women's Health Council at their website: